Beyond Consent: Sustained Moral Responsibility in Ethical Organ Transplantation

Ehtuish FA Ehtuish¹,²

1.  Surgery Department, Faculty of Medicine Tripoli University
2. President of the Libyan Transplant Authority

E-mail: [email protected]
[email protected]

Web: https://www.ehtuish.com/ar

OPEN ACCESS

PUBLISHED: 31 January 2026

CITATION: Ehtuish, E., F.A., 2026. Beyond Consent: Sustained Moral Responsibility in Ethical Organ Transplantation. Medical Research Archives, [online] 14(2). https://doi.org/10.18103/mra.v14i2.7189

COPYRIGHT: © 2026 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are credited.

DOI: https://doi.org/10.18103/mra.v14i2.7189

ISSN 2375-1924

ABSTRACT

Informed consent has long been regarded as the ethical cornerstone of organ transplantation. While indispensable, consent alone is increasingly recognized as insufficient to guarantee ethical legitimacy, particularly in living organ donation and in transplant systems operating under social vulnerability, economic pressure, or weak regulatory oversight. This conceptual ethics article advances the framework of Sustained Moral Responsibility (SMR), arguing that ethical accountability in organ transplantation must extend beyond the moment of consent to encompass enduring moral obligations across the entire transplant continuum. Drawing on bioethics, relational ethics, care ethics, and global health justice, the article conceptualizes SMR as a shared, longitudinal responsibility involving donors, recipients, healthcare professionals, institutions, and the state. The framework is discussed in relation to living organ donation, post-transplant care, and transplant governance, with particular relevance to low- and middle-income and fragile health systems. The article concludes that embedding SMR into ethical analysis and policy strengthens donor protection, public trust, and moral resilience in transplantation practice.

Keywords:

• Organ transplantation ethics
• informed consent
• moral responsibility
• living donation
• transplant governance
• self-sufficiency

Introduction

Organ transplantation represents one of the most ethically charged practices in contemporary medicine. It uniquely combines life-saving benefit with the intentional exposure of donors—particularly living donors—to medical, psychological, and social risk. Historically, ethical legitimacy in transplantation has been grounded primarily in informed consent, reflecting the centrality of respect for autonomy in modern bioethics (Beauchamp & Childress, 2019). However, a growing body of ethical scholarship has demonstrated that consent, while necessary, is not sufficient to secure moral integrity in transplantation (Truog, 2008; Ross & Thistlethwaite, 2016). Consent may be obtained under conditions of subtle coercion, structural vulnerability, or moral pressure, particularly within families and economically constrained societies. Moreover, consent-based frameworks tend to localize ethical responsibility to a single moment in time, neglecting the long-term consequences of donation and transplantation. Ethical controversies in kidney and other solid organ transplantation—including exploitation, inequitable access, donor neglect, and commodification—have been extensively documented (Ehtuish, 2011; Scheper-Hughes, 2007). These challenges underscore the need for a broader ethical paradigm. This article proposes Sustained Moral Responsibility (SMR) as a conceptual framework that extends ethical accountability beyond consent toward enduring moral obligations shared across actors and institutions.

2. Informed Consent: Ethical Centrality and Conceptual Limits

2.1 The Moral Role of Consent

Informed consent emerged as a safeguard against abuse and paternalism, affirming individual autonomy and self-determination. In transplantation, consent functions as a prerequisite for ethical permissibility, protecting donors and recipients from non-voluntary intervention (World Health Organization, 2010).

2.2 Consent Under Constraint

Despite its normative status, consent often operates within contexts that compromise voluntariness. Familial expectations, cultural norms of sacrifice, religious interpretations, and economic dependency may shape decisions in ways that are ethically significant yet procedurally invisible (Baylis & Downie, 2002; Gill, 2014). Studies examining reluctance and hesitancy toward organ donation further demonstrate how social trust, institutional credibility, and perceived fairness influence decision-making (Ehtuish, Ehtuish & Baker, 2024).

2.3 Temporal and Moral Insufficiency

Consent authorizes a specific act but does not account for downstream consequences. Long-term donor morbidity, psychological distress, social disadvantage, and lack of follow-up care frequently fall outside formal ethical scrutiny (Sharp, 2006). This temporal limitation reveals a fundamental weakness in consent-centered ethics: moral responsibility is treated as finite rather than enduring.

3. Sustained Moral Responsibility: A Conceptual Framework

3.1 Definition

Sustained Moral Responsibility (SMR) is defined as the enduring ethical obligation of all actors involved in organ transplantation to protect human dignity, welfare, and justice across the entire transplant trajectory—from pre-decision contexts to lifelong post-transplant outcomes.

3.2 Ethical Foundations

SMR is grounded in multiple ethical traditions:

• Principlism, particularly beneficence and justice, extended temporally (Beauchamp & Childress, 2019).
• Relational autonomy, which situates individual choice within social and institutional contexts (Baylis & Downie, 2002).
• Care ethics, emphasizing attentiveness, responsibility, and responsiveness over time.
• Justice-oriented bioethics, addressing structural inequities and systemic accountability (Daniels, 2008).

3.3 Core Dimensions of SMR

SMR encompasses four interrelated dimensions:

1. Temporal continuity – ethical responsibility does not end with consent or surgery.
2. Shared accountability – responsibility is distributed across individuals, institutions, and the state.
3. Outcome sensitivity – ethical evaluation includes long-term physical, psychological, and social outcomes.
4. Structural awareness – ethical legitimacy requires attention to social, economic, and political determinants.

4. Moral Agents and Shared Accountability

4.1 Donors and Recipients

Donors and recipients are moral agents, but SMR rejects the notion that ethical responsibility rests primarily on their autonomous choices. Their vulnerability necessitates protective duties from professionals and institutions (Ehtuish, 2021).

4.2 Healthcare Professionals

Clinicians bear obligations that extend beyond technical competence, including truthful risk communication, resistance to coercive dynamics, and advocacy for donor welfare before and after transplantation (Ross & Thistlethwaite, 2016).

4.3 Transplant Institutions

Institutions function as collective moral agents. Failure to provide structured long-term donor follow-up, psychosocial support, and transparent reporting constitutes moral neglect under SMR (Delmonico et al., 2011).

4.4 The State and Regulatory Authorities

States hold ultimate responsibility for ensuring equity, preventing exploitation, and sustaining ethical oversight. Ethical self-sufficiency in transplantation is inseparable from governance, regulation, and public trust (Ehtuish, 2024a; Ehtuish, 2024b).

5. Implications for Living Organ Donation

Living donation represents the most ethically demanding context for SMR. Surgical success alone cannot justify ethical adequacy. Long-term medical monitoring, psychosocial care, protection from financial harm, and social reintegration must be recognized as moral obligations, not optional benefits. SMR reframes donor follow-up as a requirement of justice and reciprocity rather than charity (Scheper-Hughes, 2007; Sharp, 2006).

6. System-Level Ethics and Transplant Governance

Consent-based ethics often fails at the system level, where inequity, corruption, and commodification may coexist with formal consent procedures. SMR provides evaluative tools for assessing transplant systems based on transparency, accountability, equity, and sustainability. In low-resource and fragile settings, SMR supports ethical prioritization and international cooperation without ethical dilution (Ehtuish, 2011; WHO, 2010).

7. Discussion

7.1 Ethical Advantages of SMR

SMR strengthens ethical resilience, enhances public trust, and aligns transplantation ethics with lived realities. It integrates individual, institutional, and societal responsibilities into a coherent moral framework.

7.2 Anticipated Critiques

SMR may be criticized as overly demanding or impractical. However, ethical adequacy cannot be reduced to procedural convenience. SMR articulates responsibilities that already exist implicitly but are frequently ignored or externalized.

8. Conclusion

Informed consent remains a necessary condition for ethical organ transplantation, but it is not sufficient. Sustained Moral Responsibility offers a robust ethical framework that captures the enduring moral obligations inherent in transplantation. By moving beyond consent toward continuous accountability, transplant systems can better protect donors, honor recipients, and uphold human dignity across diverse global contexts.

Acknowledgements:

We extend our deepest gratitude to all organ donors, whose courage and generosity make transplantation possible. Their altruism not only saves lives but also inspires the entire medical community. We also acknowledge the multidisciplinary teams whose expertise and dedication ensure the safety of donors and the success of recipients. Special thanks are also due to the families of donors, who provide unwavering support and sacrifice for the well-being of others. Finally, we appreciate the contributions of researchers, educators, and institutions who continuously advance the science and ethics of transplantation.

Conflict of Interest Statement:

The authors declare no conflict of interest.

Funding Statement:

The author declared that he has not received any funding or grants in support of the presented article or for the preparation of this work and has no declarations of potential conflicts of interest.

Corresponding author:

Ehtuish F. A. Ehtuish, Libyan National General Authority for Organ tissue and cell transplantation, Tripoli, Libya 22622.

References:

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford: Oxford University Press; 2019.
2. World Health Organization. Guiding Principles on Human Cell, Tissue and Organ Transplantation. Geneva: WHO; 2010.
3. Delmonico FL, Domínguez-Gil B, Matesanz R, Noel L. A call for government accountability to achieve national self-sufficiency in organ donation and transplantation. Lancet. 2011;378:1414–1418.
4. Sharp LA. Strange Harvest: Organ Transplants, Denatured Bodies, and the Transformed Self. University of California Press; 2006.
5. Scheper-Hughes N. The tyranny of the gift. American Journal of Transplantation. 2007;7:507–511.
6. Truog RD. Consent for organ donation. New England Journal of Medicine. 2008;358:1209–1211.
7. Gill MB. Living kidney donation and autonomy. Journal of Medical Ethics. 2014;40:1–5.
8. Ross LF, Thistlethwaite JR. Ethical issues in living donor transplantation. American Journal of Transplantation. 2016;16:1377–1384.
9. Baylis F, Downie J. Relational autonomy and health care ethics. Social Science & Medicine. 2002;54:1–14.
10. Daniels N. Just Health: Meeting Health Needs Fairly. Cambridge University Press; 2008.
11. Ehtuish FA. Ethical controversies in organ transplantation. In: Ortiz J, Jason A, editors. Understanding the Complexities of Kidney Transplantation. IntechOpen; 2011.
12. Ehtuish FA, Ehtuish F, Baker A. Understanding the hesitancy: A study on reluctance towards organ donation. Arab Board Medical Journal. 2024;25(2):53–61.
13. Ehtuish FA. Self-sufficiency and equitable access in organ, tissue, and cell transplantation. In: Bridging the Gap and Saving Lives. IntechOpen; 2024. doi:10.5772/intechopen.1007602
14. Ehtuish FA. Ethics of organ donation and transplantation: Toward self-sufficiency. Experimental and Clinical Transplantation. 2024;Suppl 5:30–34.
15. Ehtuish FE. The Transplantation Protocols. Lambert Academic Publishing; 2021.
16. Delmonico FL. The implications of Istanbul Declaration. Transplantation. 2009;87:122–126.
17. Matesanz R, Domínguez-Gil B. Strategies to optimize deceased donation. Transplantation Reviews. 2007;21:177–188.
18. Caplan AL. Ethical and policy issues in organ transplantation. Kidney International. 2011;80:243–247.
19. Kahn JP. Moral responsibility in medical systems. Bioethics. 2015;29:327–334.
20. Pellegrino ED. The internal morality of clinical medicine. Journal of Medicine and Philosophy. 2001;26:559–579.
21. Childress JF. Moral responsibility in health care. Theoretical Medicine. 2000;21:1–13.
22. Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;309:184–188.
23. Wilkinson TM. Ethics and the acquisition of organs. Journal of Medical Ethics. 2011;37:546–549.
24. Hippen BE. In defense of a regulated market in kidneys. Journal of Medicine and Philosophy. 2005;30:593–626.
25. Nuffield Council on Bioethics. Human Bodies: Donation for Medicine and Research. London; 2011.
26. United Nations. Human Rights and Bioethics. UN Publications; 2005.
27. WHO Task Force on Donation and Transplantation. Global Observatory on Donation and Transplantation. 2022.
28. Budiani-Saberi DA, Delmonico FL. Organ trafficking and transplant tourism. Clinical Journal of the American Society of Nephrology. 2008;3:567–573.
29. Potts M. Justice and reciprocity in organ donation. Bioethics. 2019;33:101–109.
30. Veatch RM. Transplantation ethics: a moral compass. Hastings Center Report. 2010;40:19–27.