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Designated organ donation: private choice in social context.

continuing feature of organ transplantation is the scarcity of available organs. Policies have attempted to manage the supply more efficiently as well as increase the supply itself. Thus, consciousness drives have been launched by various agencies to increase public awareness of the need for more organs and to increase the number of precommitted voluntary donors carrying donor cards; health care personnel, especially in the acute, intensive, and emergency care settings, have begun to be trained on how to approach the next-of-kin of moribund and of brain-dead patients about the possibility of donation; special units have been set up as flying recovery teams; and so on.

While all these efforts have ameliorated the shortage somewhat, they have certainly not solved the problem. The situation therefore raises the classic question of how to allocate scarce but vital resources in an ethically acceptable fashion.

In addressing this issue, the transplant community has set up waiting lists and developed criteria for ranking prospective recipients as to priority of access. These criteria usually focus on factors such as the urgency of the patient's medical status and the likelihood of a successful outcome of a transplantation. All other things being equal, those patients with the most acute need will receive the first available organ consistent with compatibility and likelihood of rejection, physiological fit, etc. But other factors are often considered, such as the psychological attitude of the prospective recipient toward transplantation, the existence and nature of a support group, and the ability to defray the costs that will arise in the post-transplantation period. In some countries, such as Great Britain, age is also considered-usually as an absolute and limiting criterion. Physiological suitability and likelihood of successful outcome are not, therefore, always decisive. Evasive Maneuvers

The first thing a prospective recipient must do, therefore, is to get on a waiting list. But this provides no guarantee of receiving an organ. It has happened (and will continue to happen) that persons on waiting lists-even individuals high up in the ranking-have died before a transplant.' sequently it is not surprising that someone on a waiting list, and especially someone lower down, should attempt to shorten or even circumvent the allocation process entirely by initiating a public appeal for an organ to be donated specifically to him or her. 2 Or, particularly for pediatric patients, some individual or group of individuals-parents, next-of-kin, service groups-may launch an appeal on behalf of the affected person. These public appeals highlight the plight of the individual in the most graphic terms imaginable and utilize the whole gamut of available media services, particularly television, which cannot be surpassed in its ability to generate an emotional and direct response.

Such a campaign is eminently understandable. It both expresses the fundamental desire of the prospective recipient to live, and indicates concern and solidarity on the part of others.3 Public appeals can be successful in producing an organ for the affected individual, and incidentally may result in an overall increase in the number of organs that are generally available, thereby improving the chances for other prospective recipients.

Nevertheless, serious ethical problems are raised not only with respect to such a campaign itself but for everyone involved in the process: the media, the physician, the prospective recipient-and even the donor. Nor are institutions in which the transplantation occurs immune from ethical challenge. The Ethical Nature of Organ Donation

These concerns can be clarified if we first examine the nature of organ donation itself Thomas H. Murray in particular has focused on organ donation as a gift relation, and suggested that it may be seen as serving a variety of social functions. It may "signal that self-interest is not the only significant human emotion" and that "it is good to minister to fundamental human needs"; remind us that not all valuable things like love, a feeling of fellowship, trust, etc. can be purchased"; affirm the solidarity of the community over and above the depersonalizing, alternating forces of mass society and market relationships"; or "create and sustain intimate personal relationships."

Yet this correctly tells only part of the story; there is another aspect of organ donation that is crucial to understanding the ethical nature of organ donation itself It concerns the meaningfulness of such donations.

Unlike most other gift transactions, organ donations are not complete within themselves. They are not like transactions where the value and significance-indeed the very nature of what is given-is a function solely of the interaction between the donor and the recipient and the gift transaction consists essentially in the transfer of these items from one person to another. For instance, gifts of clothing, food, and shelter are gifts of items that are significant in and by themselves. Although these gifts may also have various socially important purposes and functions, none impose an obligation on others to do something so that the gift may become meaningful and significant as that kind of gift: as a gift of the sort of thing the donor had in mind. To put this more concretely, the gift of a liver, a kidney, or a heart as such, to someone who requires an organ, is useless. Without active social involvement and intervention, it is merely the giving of a piece of human flesh. To become a gift in the sense that both we as members of society as well as the donor and the recipient understand, the donation must take place in a heavily institutionalized context consisting not only of the medical transplant team but of a whole array of support services without which transplantation itself would not be possible. These include recovery and delivery services. Then there is the planning, funding, and actual integration of the biotechnical support services that are necessary for the actual operation itself-a task that spans various departmental and administrative levels. Social and medical postoperative services are also implicated, as is counseling for next-of-kin and recipients-and sometimes even the health care professionals themselves. Furthermore, as a medical modality, transplantation is functionally dependent on historical developments that span millennia of social effort to advance the art and science of medicine. A myriad of other social developments and involvements stand behind transplantation and make organ donation possible and meaningful as an act. They are what give it significance as the gift of an organ rather than merely the discarding of human tissue.

Therefore organ donation is not only a personal action but also a social act. It is a social act not solely because it is embedded in a social context-most gift transactions have that nature-but because it requires society's direct and immediate participation. Society itself becomes a participant giver, and the organ, which as tissue was merely a private good, becomes a social good when it is an organ-as-donated. Access and Ranking

This fact of social involvement has important consequences. Procedurally, it entails that if there are formal constraints that govern social acts per se, then these will also apply to organ donation. Legal, social, and political parameters will here be implicated. But it also entails ethical constraints; constraints that derive from the principles of equality, justice, and respect for persons and which govern all social interactions in a fundamental way.

If we focus on the latter, the suspicion may arise that selective allocation in general and ranking in particular violate these ethical constraints. After all-so it might be argued-the principle of equality formally states that all persons are equal. Does this not entail that they must all be treated the same? Does this not in turn mean that there cannot be, even in principle, any way of distinguishing between prospective recipients, let alone of ranking them? For ranking, by its very nature, requires that individuals will be treated differently-namely, with respect to opportunity of access. Consequently, it might be concluded, we have only two ways of guaranteeing equality of treatment: to provide no one with an organ and abandon transplantation entirely until the problem of resource insufficiency has been solved, or to adopt a randomized lottery system of distribution in which there is no ranking at all.

The mistake in such reasoning lies in the interpretation of the principle of equality of persons. While the principle does prevent us from discriminating between persons as persons, it does not prevent us from discriminating between their competing claims. The strength of their claims may differ depending on such factors as degree of need, nature of the need, its origin,-' and the probability of a successful outcome upon intervention.6 Thus, the general rule is: so long as the characteristics on which the discrimination/ranking is based are not preselective in a way that violates equality and justice, they may be used as distinguishing parameters. To put it differently, all and only those characteristics may be used as ranking criteria that are condition-specific; person-specific characteristics that is, those that by their very nature guarantee that only preselected persons will benefit, may not. Futhermore, it must be essentially a matter of chance, beyond the control of the individual or interested third parties, whether he or she has these characteristics.

These considerations allow us to allocate subjectively in the way that we have indicated: both by controlling entry into the pool of prospective recipients; and then by letting us construct a two-tier ranking system within the pool itself. Here, prospective recipients can first be ranked on the basis of criteria justified by the equality-and-justice rule. Then, if there are still candidates whose claims are indistinguishable, we can turn to an egalitarian lottery system: Since ex hypothesi the candidates that are left will have equal claims, any lottery approach that gives each the same chance will not subvert equality and yet at the same time will allow for selective allocation.7 Designated Donation It is in this very regard, however, that designated organ donation differs. It is person-specific, and thereby abandons the general ethical framework. Rather than focusing on conditions that ultimately are defensible in terms of equality and justice, it ties access to an organ to the emotional appeal (or lack thereof) of the prospective recipient, the public relations skills of the physician(s) involved, of the next-of-kin and of those who orchestrate the media campaign, and the financial abilities of everyone concerned to mount such a campaign in the first place. Designated organ donation in effect singles out a specific individual and characterizes him or her as someone to whom an organ may be given independently of the established means of access. The assumption is that this person is ethically special; that he or she has some particular quality or characteristic that permits an exemption from the criteria that otherwise apply to all. Of course, it is possible that such a person does have some special characteristic that makes him or her ethically unique-at least in this particular context. We cannot rule out a priori that there isn't some ethically relevant characteristic that was overlooked when the standard ranking criteria were formulated. However, to be compatible with equality and justice, such a characteristic must not be person-specific, but must be one that in principle anyone can have. This means the characteristic should be included in the criteria that determine the ranking in the first place. But if a new condition is added to the established set, there is then no need to go outside the proper ranking criteria to benefit this particular individual: Although in principle the characteristic could be had by anyone, it just so happens that at this time it is possessed only by this particular person. In principle, then, there is nothing wrong with introducing a new criterion. However, such a move enjoins us to ask what the criterion is, and why it should apply to just this particular person. Photogenic appeal, having private funds available for a media campaign, or having a highly motivated personal physician certainly could not be considered appropriate criteria. Nor could frustration in waiting for an organ, the fear o not getting one in time, or extreme dissatisfaction with the current quality of life while waiting. These criteria either involve a violation of equality and justice, or are common to al prospective recipients, and therefore are not ethically distinguishing. Famiily Ties There is one characteristic that is ethically distinguishing and that does amount to a uniquely qualifying property in the case of a particular person: having an immediate family tie to a specific donor. Parents, in virtue of assuming the role of parents, have accepted an obligation of support and nurture for their child. This obligation may reasonably be understood as a requirement to do the best for the child so long as that does not involve undue, inordinate, or unreasonable risk for the parent. Since organ donation (in a medically acceptable fashion) does satisfy these conditions-all other things being equal, it will not involve the donation of the one remaining kidney, or of a heart by an as yet still living parent-and since donation itself can reasonably be interpreted as providing "the necessaties of life," it may be argued that it is merely the extension of an otherwise existing duty that does not hold for others or in other contexts." Following the suggestions of Murray and others, if the giving of a gift may raise reasonable expectations of return-especially in a social context where such an expectation is not only considered acceptable but is well-entrenched-then this also provides a unique and differentiating condition. While the parents may not expect support and the necessaries of life as a matter of payment, they do have a socially sanctioned expectation that does not exist in other cases. That expectation will be a variable that may legitimately count as an exception to the rule of otherwise impartial distribution. It honors the value that society places on the existence of the family unit itself.

This last consideration is important in the case of sibling donation. To be sure, there are practical considerations that play a role. The likelihood of a match is greater here than in other cases, and whatever the psychological factors might be that positively contribute to a better success rate, they are likely - to be present to a greater degree in these contexts than in most others. Considered by themselves, these do not amount to ethical justifications for designated sibling donation in contravention of the equality-and-justice rule. However, the peculiar strength and nature of the interpersonal relationship within the immediate family context coupled with the special role that society accords to the family unit itself, is such a justification. The fact of inter-sibling identification, which manifests itself in the supportive stance that siblings may take with respect to each other, and the mutually reciprocal relationship that has developed between them over the time of their growing together must also be considered.' Interspousal designated donation is, of course, different. Whatever the exact formalization of their association as spouses may be-and here the various sociocultural and ethnic groups do differ-the spouses have agreed to provide mutual support and succor for each other to a degree that is not recognized outside of this sort of setting. And society, by recognizing the special nature of this association, acknowledges its uniqueness and strength. It would therefore be contradictory of society to recognize the special nature of this association, give it formal expression, place specific expectations upon it-and then deny the individual members of that association the right to act on it in actual practice. If one of the primary functions of gift-giving is to create and sustain intimate personal relationships," and if society recognizes the spousal relationship as being of a uniquely intimate and exceptionally desirable sort, then the very act of so recognizing it creates just the special kind of relationship that ethically allows for an exception to the rule of impartial allocation. Family ties, then, are uniquely privileging and identifying, and designated organ donation occurring within the immediate family context does not violate the equality-and-justice condition. However, when there is such a tie, and when there is a willing donor who falls under this rubric, there is no need of a public appeal for a designated donation. As an exceptive condition to the rule, therefore, family ties are acceptable-but practically speaking make no difference. No public appeal will be necessary or forthcoming. The Media

When we examine the ethical positions of various parties outside of the family context for designated organ donation we immediately encounter a whole host of problems. Let us begin with the media. It can be argued that media involvement serves to heighten public awareness of the organ scarcity as well as of the particular need that exists. Thus, whether or not it is successful in producing an organ suitable for the designated individual, it often can effect an overall increase in the number of organs donated.

These possibilities should not be allowed to obscure several important ethical considerations. First, the need of the particular recipient is not isolated or unique. There exists a whole array of competing needs of the same kind-namely the need of every other prospective recipient. By focusing on the need of one person, and participating in a campaign to satisfy specifically it, the media remove that need from the comparative context that allows the public to assess its ethical significance properly. By virtue of presenting the person's need in this fashion-isolated and divorced from its comparative context-the media would be characterizing it as something special: as something that not only invites a supererogatory act of donation in general, but an act focused on this particular need of a particular person. In this manner, therefore, the media would effectively falsify the true state of affairs.

As a result of this falsification, it may happen that someone who otherwise would have made an undesignated donation donates to this specific individual-thereby diminishing the overall organ pool. This however, means that someone who ethically would have been a more appropriate candidate-that is, someone who is higher on the waiting list-would lose what rightfully is his or hers. The person might even the as a result of this loss. A considerable part of the blame for this outcome would lie at the doorstep of the media.

An additional problem with media participation in a designated organ donation campaign concerns the general ethical attitude that such involvement would foster: In championing the cause of the particular individual outside of the otherwise established allocation system, the media would be advancing the position that one may legitimately circumvent whatever ethically appropriate orders, limits, or procedures there are to achieve one's own private ends. The very fact of their participation would foster an attitude that private ends outweigh ethical fights. Not only is this false per se, it is also at least arguable that the media, by virtue of their social role, have an obligation not only to present information to the public but also to present it in an appropriate and truthful manner!' There are situations in which this is difficult to do, especially when the data are themselves unclear. Here, however, that is not the case. Therefore while the media may present a specific individual to the public, they should do so only in such a way as to allow the public to appreciate his or her true ethical position. This means that the person may be presented only as one among many others who need organs, only as someone whose plight typifies the situation of those on waiting lists. Anything else would not only constitute participation in a subversion of the rights of those on waiting lists, but also involve misleading the public. By that very token, it would be a violation of a professional trust. The Donor

At first glance, the donor's position seems unaffected by these considerations. After all, whatever the social functions and implications of his or her act may be, the person is performing a supererogatory act, for which he or she deserves praise, not blame. Moreover, the principle of autonomy affirms the right of self-determination, which may be extended to the right of disposing of what is one's own. Shouldn't this mean that the donor has a fight of disposition with respect to his or her organs even in a donation to the recipient of his or her choice?"

This train of reasoning may initially strike us as extremely reasonable. Closer consideration, however, shows that it is based on the premise that the act of donation lies entirely within the power of the donor as to its nature and direction. That premise is mistaken. The fact that a donation qua act lies within the power and discretion of a donor does not entail that the donor may exercise that power as he or she may see fit. For the principle of autonomy does not mean that everyone has an unqualified right of self determination-of complete freedom of action, no matter what-but rather that this right of self-determination holds subject to the competing and legitimate rights of others. In Rawlsian terms, "acting autonomously is acting from those principles that we would consent to as free and equal rational beings."12 The principle of autonomy therefore carries a logic of limitation within itself- It requires a balancing between the rights of the individual who claims autonomy and the competing legitimate rights of all others, where that balancing must occur in terms of equality and justice. Hence, if the otherwise free and unconstrained choice of an individual infringes on equality and justice, it will not be a legitimate exercise of autonomy and must be rejected.

If we apply this logic to designated organ donation, we can see immediately why the donor cannot appeal to the principle of autonomy to ground his or her light to designate the nonfamilial recipient. Organ donation is not an act that is complete in itself It is a social act. Directly or indirectly it involves all of society. Consequently it is subject to general ethical constraints, including equality and justice. The fact that the act originates voluntarily from the donor does not alter this.

If the donor wants to be ethical, he or she must act within these moral constraints. If the organ is donated outside of these constraints, then what was intended as an ethically praiseworthy act becomes a deplorable act of discrimination. While materially it will undoubtedly have importance, ethically it loses its value. The Health Care Institution

The social nature of organ transplantation also is of relevance for health care institutions are publicly funded or are part of a socialized helath care system. In these cases, trivally, the institutions depend on society and operate under an expres mandate to provide health care in an equitable fashion. By their very naure, such institutions will be barred from participating in non-familal designated organ donation schemes, whether in a procuring or a utilizing capacity. While on occasion it might be politically expedient to depart from this approach-for example, when a high-profile recipient or a financially powerful individual is involved-that very departure would signal the breakdwon of the ethical mission of the institution.

Private health care institutions are equally not immune from these considerations, for they still operate in a social context. This makes their actions subject to the limiting principles of equality and justice. Moreover, the organs that are to be transplanted derive their significance and menaingfulness as organ from the scientific, medical, and pharmacological developments that makes donations possible. They are, in a very real sense, social goods. And, like any social agent, privat health care institutions are subject to the principle of shared responsibility; If a first party engages in an unethical act which, as act, becomes materially possible only through the aid of a second part, then the second party shares in the guilt of the first to the degree that its participation is instrumental in allowing the act to take place. Since any disignated organ donation is dependent on the health care isntitution in which it occurs, it follows that if such an institition, whether publick or private, participates in such an act, it will be subject to the principle of shared responsibility.

Under ordinary cirucmstances, with equitable and just allocation criteria in operation, the distribution of organs will still be selective-not everyone will get an organ- and becasue of that, some prospective recipient on the waiting lists will quite probably die. This death would in principle have been preventable in the sense that had the distribution been different, the patient would have received an organ and someone else who did not would have died. The distribution policy that follows from even just allocation criteria is therefore responsible for the death, in that it shifts the death from one person to another. But the fact that someone will die lies beyond the parameters of the situation itself. There will be a death, and whoever dies, the death will be tragic but not unethical. It will be the inevitable outcome of a tragic state of affairs with which society is dealing in the best way it can.

Designated organ donation, however (with the exception of the family context), alters all of this. It does not change the number of people who will die, but rather who particularly will die. Saving (or attempting to save) a specific individual who is not in the group of ranked prospective recipients creates a state of affairs that prevents relieving the need of someone in that group who but for the designation would have recieived the organ. And that is tragic as well as unethical; tragic because of the death; unethical because someone who according to equity and justice was entitled to the organ is deprived of it. And it is the institution that here is morally culpable. For had it acted ethically and refused to participate, the suggestion of designated organ donation would not have arisen in the first place. What is important and objectional, therefore, is not that the pool of organs is being depleted but how.

Nothing we have argued entails that a health care institution may not become involved in media campaigns that highlight the plight of particular persons. The identified victim syndrome is too powerful to be ignored as a public relations tool. However, the institution must make clear that any organ resulting from such an appeal will be distributed according to appropriate ranking and distribution criteria that involve all transplant institutions. Instutitional ethics demands no less. The Physician

While the ethical implications of the social context apply also to physicians, there are in addition several considerations that apply uniquely to the physician. Indeed, these considerations are relevant irrespective of whether the physician works in a private fee-for-service setting or in a socialized health care system. They focus on the fact that medicine is a monompoly. Minimally, this implies that only those who fulfill certain criteria set by the profession itself and hwo have been licensed as practitioners by the profession are legally entitled to practice. While it is arguable that some monopolies are granted by society for the benefit of the monoploy holders, this is not the case with public service monopolies. They are granted on the assumption that by allowing the profession to control entry into as well as the standards of the profession, society is assured of the best possible level of service. In addition, by accepting the monopoly, the holder binds him or herself to ensure not only quality of service but also ubiquity and universality. That is, while quality of service may be society's primary consideration in granting a monopoly, society does not envison that the monopoly holder will offer the relevant sersvice only in select locations, or only to select people who can affort to meet the (private set) fees. The ethical basis on which society purports to operate requires that equality and justice be preserved in socially mandated actions.

Medicine is a social service monopoly is bound by these ethical constraints in a much tighter fashion than lmost other undertakings. Of course it is not the ndividual physician who is the acutal monopoly holder. It is the profession as a whole, represented by the relevant professional organizations. What is important, however, and what should concern us, is hat the actions of the individual physician must be in keeping with the obligations that bind the profession as a whole. Among other things, this means that individual physicians must not select patients entirely lwith an eye to profit but must at least attempt equity; and that actions on behalf of a particular patient must not only be professionally competent but also just and fair.

Therefore, while the individual physician has an obligation to do the best he or she can for the patient, whatever acts the physician undertakes must not be engaged in as though the patient existed in isolation, divorced as it were from the rest of society. The monopolistic nature of the profession requires that the possibility of meeting the needs of others in a just and equitable fashion be taken inot account when it comes to resource allocation. At least, this msut be the case with respect to those aspects of medical practice that involve drawing on nonrenewable social goods.

The ethically sensitive transplant physician, therefore-and indeed the ehtically sensitive physician per secannot participate in a nonfamilial disignated organ procurement and/ or utilization process. It would jeopardize the lubiquity and universality of the health care services intailed by the fact of the monopoly. Furthermore, equality and justice would be denied through preferential access. Instead, the physician must actively reject any such undertaking and must publicly condemn any such attempt lest through professional silence on the matter a situation be allowed to develop that the profession itself could not ethically accept. The Recipient Given what we have already argued, the position of the designated recipient can be sketched rather quickly. Under normal circumstances of gift-giving, where the gift or donum is not a social good and does not depned for its significance as a gift on social involvement, the giver's intention to donae to a specific indiividual would be sufficient justification for the intended recipient to accept the gift should he or she feel so inclined. The situation here, however, is different. The organ that is given as a figt is a social good, which means that the limiting parameters that affect the position of all other participants affect the prospective recipient as well. More specifically, it means that the lindividual cannot request a designated donation, and when designated as recipient with or without such a request, he or she cannot accept. He or she must gently reject the offer, that is, without denigrating the laudable spirit that underlies the donation as a donation, and without offending the sensibilities of the donating person. But reject it he or she must.

Two additiona considerations may merit special attenion. The first centers around the act of acceptance and what it suggests. To follow a point made by Willam Wollaston, "whoever acts as if things were so, or not, doth by his acts declare, that they are so, or not so; as plainly as he would by words, and with more reality. And if things are otherwise, his acts contradict those propositions, which assert them to be as they are." That is to say, by accepting the designated donation, the intended recipient in effect holds him or herself as ethically so special that he or she is not subject to the general constraints that govern social interactions. In that sense, and to that degree, he act of acceptance has an inherent and ineluctable fraudulent parameter. It is, so to speak, a lie.

A second point is analogous to a consideration that we adduced on the positon of health care institutions. Since the pool of available organs is limited, any interference with its ethical distribution will result in a shift in the distribution pattern, so that someone who ethically is entitled to an organ will not in fact receive it. To accept a disignated donation is to interfere in the distribution pattern and to take something that, all other things being equal, someone else shold have. Unless there are extenuating circustances, to take something to which one is not entitled and away from someone who is, is to commit theft. Since there is here no question of entitlement on the part of the intended recipient-ex hypothesi the criteria that would confer entitlement are here not being met-the latter, by accepting the designated donation, will be committing theft.

It could, of course, be argued hat since the organ is freely given by the donor but only to the designated recipent, the situation is altered: The donation is either for this individual or not at all. Thus, talk about theft is entirely out of place. This reasoning, however, fails. The donar is free to give or not, as he or she pleases; and in that sense, the size of the available organ pool is not a predetermined matter. However, once he or she has decided to give, the donation is subject to the constraints of equality and justice. This means that if it really is given-if it really is to be used an an organ-it does become part of the pool whose distribution must adhere to these ethical principles. It also means that if the designated recipient accepts the organ in violation of these, he or she will be committing theft. The claim tht it is better that he designated recipient accept the organ and be saved than theat the designated recipent refuse, the donation be withdrawn (because it was intended only for this person)and therefore a person who could have been saved now die without any compensating saving relative to the ranked prospective recipients, has little to recommend it ethically. Not even a utilitarian would accept this view, because it would mean abandoning equality and justice as operational principles.

Whatever its sociological and psychological functions, oragan donation is an ethically praiswworthy act whose purpose is to benefit others. It sets into motion a train of events that is designed to ensure that the donated organ will not be wasted, precisely because the gift is so precious nor that in itself the act is praiseworthy should be allowed to obscure the further fact that organ donation does not occur in a social vacuum. Its meaningfulness as an act, to say nothing of its possibility, presupposes a health care delivery system that has ineluctable social parameters. These parameters entail considerations of equality and justice and therefore imply an ethical ban against procedures that do not abide by them. Organ donation is an ethically praiseworthy act, to be sure; but only when it remains within the ethical framework that governs all social interactions. social agent, private health care institutions are subject to the principle of shared responsibility: If a first party engages om an unethical act which, as act, becomes materially possible only through the aid of a second party, then the second party shares in the guilt of the first to the degree that its participation is instrumental in allowing the act to take place
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Author:Kluge, Eike-Henner W.
Publication:The Hastings Center Report
Date:Sep 1, 1989
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