Organ donation following medical assistance in dying, Part I: a scoping review of legal and ethical aspects

Abstract

Objective:

The objective of this review was to collate and summarize the current literature on what is known about organ donation following medical assistance in dying (MAiD). Additionally, for this first part of a 2-part scoping review, the focus is on legal and ethical considerations regarding organ donation following MAiD.

Introduction:

Organ donation following MAiD is a relatively new procedure that has sparked much debate and discussion. A comprehensive investigation into the legal and ethical aspects related to organ donation following MAiD is needed to inform the development of safe and ethical practices.

Inclusion criteria:

In this review, we included documents that investigated legal and/or ethical issues related to individuals who underwent organ donation following MAiD in any setting (eg, hospital or home) worldwide. We considered quantitative and qualitative studies, text and opinion papers, gray literature, and unpublished material provided by stakeholders.

Methods:

This scoping review followed JBI methodology. Published studies were retrieved from databases, including MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Web of Science Core Collection, and Academic Search Complete (EBSCOhost). Gray and unpublished literature included reports from organ donation organizations in Canada, The Netherlands, and Belgium. Two independent reviewers screened all reports (both by title and abstract and by full text) against the inclusion criteria, extracted data, and completed a content analysis. Disagreements between the 2 reviewers were resolved through discussions among the reviewers and the lead reviewer.

Results:

We included 121 documents for parts I and II of our scoping review, 89 of which are included in part I. The majority of the 89 documents were discussion papers published in English and in Canada from 2019 to 2021. In the content analysis, we identified 4 major categories regarding ethical and legal aspects of organ donation following MAiD: i) legal definitions, legislation, and guidelines; ii) ethics, dilemmas, and consensus; iii) consent and objection; and iv) public perceptions. We identified the main legislation regulating the practices of organ donation following MAiD in countries where both procedures are permitted, the many ethical debates surrounding this topic (eg, eligibility criteria for organ donation and MAiD, disclosure of donors’ and recipients’ information, directed organ donation, death determination in organ donation following MAiD, ethical safeguards for organ donation following MAiD), as well as the public perceptions of this process.

Conclusions:

Organ donation following MAiD has raised many legal and ethical concerns regarding establishing safeguards to protect patients and families. Despite the ongoing debates around the risks and benefits of this combined procedure, when patients who request MAiD want to donate their organs, this option can help fulfill their last wishes and diminish their suffering, which should be the main reasons to offer organ donation following MAiD.

Introduction

Medically assisted death is a process that is legal in many countries (eg, The Netherlands, Canada, Belgium^1–3) under certain circumstances. The terms used to describe assisted death vary globally; for example, in Belgium and The Netherlands, this process is called euthanasia or physician-assisted suicide; in Canada, the provision of assisted death is called medical assistance in dying (MAiD), which is the term used in this review. MAiD is a multifaceted process, and its use has sparked controversy and led to complex discussions across the globe.⁴ The availability of MAiD has allowed for controlled organ donation following MAiD in some countries, including Canada, The Netherlands, Belgium, and, most recently, Spain.^5–7 MAiD can occur through self-administered MAiD (the patient administers the medication that will result in terminating their life) or through clinician-administered MAiD (a clinician administers the medication that will result in the termination of the patient’s life).² However, for the context of this review, we will use the acronym MAiD to denote clinician-administered MAiD only, as organ donation is not currently possible after self-administered MAiD due to the risk of damage to organs from prolonged warm ischemia time.^2,8,9

The history of organ donation following MAiD is relatively new, with the first case described in the literature in 2008 (from the first case performed in Belgium in 2005), and since then, there have been many ethical, legal, and moral debates and contradictory discussions concerning this process.^10,11 Organ donation following MAiD has raised concerns regarding patients’ safety and autonomy, including debates around the determination of death, the dead donor rule, the impact on patients’ end-of-life experience, acceptable procedures, public perception, and others.¹²

There are many discussions regarding legislation and guidelines for organ donation following MAiD because when changes in legislation occur, the guidelines also need to be updated to reflect the legislation and ensure the process is safe, fair, and ethical. For example, in Canada, Bill C-7 on MAiD legislation recently updated the eligibility criteria for patients who request MAiD (eg, regarding differences in the process between patients whose natural death is not reasonably foreseeable and whose death is reasonably foreseeable). This change in the MAiD legislation now requires modifications in the practice guidelines to ensure acceptable procedures for organ donation following MAiD.¹³

Despite organ donation following MAiD being a potential avenue to reduce the organ shortage,¹⁴ ethical, moral, and legal safeguards need to be in place to protect patients and health care professionals involved in the process. Even though there has been an increased number of publications discussing organ donation following MAiD in recent years, no rigorous review of the literature around ethical and legal aspects has been performed to inform the development of new regulations and practice guidelines. Therefore, in this first part of a 2-part review, we focused on ethical discussions (eg, death by donation), legal aspects (eg, legislation specific to MAiD and/or organ donation), and other aspects that can influence the ethical and legal processes (eg, public perception).

A preliminary search of MEDLINE, Epistemonikos, PROSPERO, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was performed prior to the development of this review, and no current or ongoing systematic or scoping reviews were identified on this topic. We used scoping review methodology for its iterative approach and exploratory nature. This approach allows a comprehensive review of published and unpublished literature. Due to the novelty of organ donation following MAiD, many records used to guide current practice for organ donation organizations worldwide might not be published as scientific evidence or be publicly available. Therefore, we aimed to collate and summarize the current global literature on the existing legal and ethical aspects of organ donation following MAiD.

Review questions

In our research protocol,¹⁵ we presented an overarching research question (What processes, procedures, and outcomes have been reported in the literature worldwide about organ donation following MAiD?), which was followed by 6 subquestions. In this first part of the 2-part review, we address 4 subquestions, with the remaining questions addressed in a separate paper.⁹ This first part addressed the following subquestions:

1. What legislation and processes are in place to regulate organ donation following MAiD?

2. What ethical aspects have been discussed regarding directed organ donation following MAiD?

3. What are the different types of donations allowed for patients who request MAiD?

4. How is consent for MAiD and for organ donation requested from conscious patients and from patients who may lose capacity due to base illness?

Inclusion criteria

Participants

For this review, we considered reports that included any individuals who underwent organ donation following MAiD (regardless of age or medical conditions). If the focus of the report was on individuals who chose withdrawal of life-sustaining measures, the source was excluded because this procedure does not qualify as MAiD.

Concept

We included reports that explored or described legal and ethical aspects (eg, legislation, death by donation) of organ donation following MAiD, as well as influencing aspects (eg, public perception). Various terms are used for MAiD and organ donation internationally. Therefore, we included other terms for organ donation, such as organ and tissue procurement, organ transplantation, transplantation, donation after circulatory death, organ donation after circulatory determination of death, non-heart-beating donation, organ retrieval, organ procurement, dead donor rule, tissue and organ harvesting, organ donor, tissue donor, deceased donor, living donor, donor, and body donation. We also included other terms for MAiD, such as assisted suicide, euthanasia, voluntary euthanasia, active euthanasia, assisted dying, assisted death, doctor-assisted suicide, physician-assisted suicide, medically assisted suicide, accompanied suicide, voluntary assisted dying, physician-hastened death, physician-assisted death, and right to die. However, discussions that focused exclusively on the ethics of offering organ donation to patients who have chosen MAiD were not included, as this process is already an established practice where legally permitted. Reports on both organ and tissue donation were included, but if the focus was on tissue donation only, then the report was excluded, as the focus of this review is specific to organ donation.

Context

Reports within the context of organ donation following MAiD in any setting (eg, home, hospital, others) were considered. Sources from any country were considered, recognizing that at the time of the literature search in December 2021, organ donation following MAiD was performed only in Canada, Belgium, and The Netherlands. Of note, organ donation following MAiD started in Spain in 2022.

Types of sources

We considered reports that used a variety of designs, including experimental, quasi-experimental, analytical observational, descriptive, case reports, qualitative, text and opinion papers, editorials, and reflective or ethical studies. Additionally, abstracts were included, and authors were contacted to check the availability of the full text. Lastly, unpublished material (eg, unpublished reports shared by organ donation organizations), gray literature (eg, theses and dissertations), and news articles were also considered if relevant to the topic. Laws and regulations were not included, but if they were mentioned in the reports selected for inclusion, we searched for the original source to complement our results and discussion.

Methods

This review was conducted using the JBI methodology for scoping reviews.¹⁶ This methodology allows for the collection of data from published and unpublished literature, using a broad but precise research question and a systematic search process.¹⁷ The title of this review was registered in the JBI Systematic Review Register,¹⁸ and a protocol was developed and published¹⁵ to guide the review.

Search strategy

A search strategy was developed by an experienced information specialist using a 3-step search process with controlled vocabulary and keywords to locate both published and unpublished literature. An initial limited search was performed in MEDLINE (Ovid) followed by an analysis of text words in the relevant titles and abstracts, and the index terms. The keywords and index terms were used to inform the development of the search strategies tailored for each database. The searches were verified by a content expert and reviewed by a second health sciences librarian expert using the Peer Review of Electronic Search Strategies (PRESS).¹⁹ MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Web of Science Core Collection, and Academic Search Complete (EBSCOhost) were searched. Gray literature and unpublished material were searched through Google, OpenGrey, and websites of organ donation organizations from countries where donation after MAiD was allowed (Canada, Belgium, and The Netherlands, as of the date of the literature search); information was also requested from key stakeholders. For the search of gray/unpublished literature, we combined the terms organ donation and MAiD, as described in the population and concept only, because those websites did not allow the use of Boolean operators. Lastly, the reference lists of all included reports were screened for additional sources.

We did not exclude any material based on language. As the first case of MAiD was described in 2008, we considered reports published from 2000 onward to obtain studies on the topic and earlier discussions around this process. The full search was conducted on March 6, 2021, and updated on December 4, 2021. The final search strategies for the included databases are presented in Appendix I.

Source of evidence selection

The published and unpublished literature retrieved was imported to EndNote 20.4 (Clarivate Analytics, PA, USA), and duplicates were removed. The remaining duplicated references not identified by the software were manually excluded during the screening process. The unique references were imported to Covidence (Veritas Health Innovation, Melbourne, Australia) for screening. To determine study eligibility, we used a 2-step screening process. First, the titles and abstracts were screened against the inclusion criteria, and then the eligible references were assessed at the full-text level for a final decision regarding inclusion. Each reference was screened by 2 independent reviewers, both in the title and abstract screening and full-text review, from members of the research team (AR, ARS, LH), and conflicts were solved through discussion among the reviewers and VSS.

Data extraction

Data were extracted by 5 independent reviewers depending on the language in which the report was written (French: LH; English: AR and ARS; Dutch: JB and JW) and verified by VSS. For the extraction process, we used a data extraction tool¹⁵ that was developed and pilot-tested for this review, and included details about study characteristics, population, concept, context, and other key aspects relevant to our primary aim and research questions i to iv. The pilot test consisted of 2 independent reviewers extracting data from 3 different reports and then undergoing a consensus process and discussing the need for any modifications in the original tool. No modifications to the original tool were necessary.

Data analysis and presentation

The references included in this review were uploaded into NVivo 12 (QSR international, United Kingdom) for a qualitative content analysis using an inductive process to create codes that were later grouped into categories to identify majority consensus across the data and to synthesize the results from this review. The data analysis was performed by 2 independent reviewers (ARS and AR) and checked by a third reviewer (VSS) for rigor and replicability. After the data analysis process, we divided the results of this review into 2 manuscripts for reporting, due to the amount of data available and to improve the clarity and readability of the manuscripts. Therefore, in this first paper, the results are reported through descriptive numerical summaries, flowcharts, and a narrative summary clarifying the findings related to review questions i to iv.

Results

Study inclusion

Details related to search results and source selection in this review can be found in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram in Figure 1.²⁰ The searches yielded 5042 records. After duplicates were removed, 1879 titles and abstracts were screened. Of these, 1538 records were excluded. We screened 341 full-text reports, and from those, 121 met the inclusion criteria. Of the 121 included sources, 89 are reported in this manuscript to respond to research questions i to iv (details on the division of results can be found in the upcoming sections and in Figure 2).^{1,3–6,8,10,12,21–101} Our attempts to locate the full text of papers that were not open access were conducted using organizational access and requests for interlibrary loans. Those that could not be accessed were excluded from the review. The primary reasons for the exclusion of references were discussion on MAiD, but not specific to organ donation; discussion on organ donation, but not specific to MAiD; and only generic mention of the topic without further discussion. The complete list of reports excluded following full-text review can be found in the supplemental digital content 1, http://links.lww.com/SRX/A27.

Figure 1.

Search results and source selection and inclusion process²⁰

Figure 2.

Scoping review findings on organ donation following medical assistance in dying, and the division into 2 parts: i) legal and ethical aspects, and ii) processes and procedures.

Characteristics of included sources

From the 89 references included in part I, most reports were published in English (n=71; 80%), from Canada (n=31; 35%), and between 2019 and 2021 (n=41; 46%). A complete list of the characteristics of included sources can be found in Appendix II.

Review findings

After performing a content analysis of the data, we identified 51 codes that were grouped into 9 categories. From those 9 categories, 4 addressed research questions i to iv (detailed descriptions of codes under the categories addressed in this paper can be found in Appendix III). The 4 categories describe the various legal and ethical aspects of organ donation following MAiD from different perspectives: i) legal definitions, legislation, and guidelines; ii) ethics, dilemmas, and consensus; iii) consent and objection; and iv) public perceptions (see Figure 2).

Legal definitions, legislation, and guidelines

In this category, we described the specific legal definitions, legislation, and practice guidelines discussed in the included reports that are used to ensure the quality and safety of procedures involved in organ donation following MAiD. We identified 59 reports that provided any type of guidance for organ donation after MAiD. There are various legislations in place to regulate MAiD, but in our searches, we did not identify specific legislation regulating the practice of organ donation following MAiD. Also, we limited our discussions to the 3 countries where organ donation following MAiD is legal (Canada, Belgium, and The Netherlands).

Organ donation following MAiD is considered a controlled donation (where the death is expected and under controlled conditions) rather than an uncontrolled donation (where the death is unexpected and occurs in uncontrolled conditions and/or settings). The Maastricht classification system is used internationally to categorize organ donation after circulatory death (DCD) in controlled and uncontrolled death (DCD I to IV).³⁵ To keep updated with the practice of organ donation following MAiD, the Belgian Transplantation Society and Belgian Transplantation Council updated the definition of DCD to include euthanasia as a new controlled DCD category V.^1,45,53,62 The updated classification nomenclature is presented in Table 1.⁴⁵ In The Netherlands, there is no official category for patients who request MAiD (eg, DCD-V in Belgium), and organ donors from MAiD are considered Maastricht category III.^24,37,44 This issue was not identified in the Canadian literature regarding the Maastricht categories, but Canada currently only performs organ donation following controlled DCD.

Table 1.

Modified Maastricht classification of donation after circulatory death⁴⁵

Category	DCD type	Description
I) Dead on arrival	Uncontrolled	Cardiocirculatory death outside the hospital
II) Unsuccessful resuscitation	Uncontrolled	Unexpected cardiocirculatory death inside the hospital
III) Awaiting cardiac arrest	Controlled	Expected circulatory death inside the hospital
IV) Cardiac arrest while brain dead	Controlled	Unexpected or expected cardiocirculatory arrest in a brain-dead patient
V) Euthanasia	Controlled	Expected circulatory death following medical assistance in dying

The first cases of organ donation following MAiD were performed in 2005 in Belgium, in 2012 in The Netherlands, and in 2016 in Canada.^4,5,35,43 Organ donation after MAiD was considered acceptable by Eurotransplant, the organization responsible for the allocation of donor organs in some European countries (including Belgium and The Netherlands), after the first case was published in 2008.^4,35,43 In The Netherlands, MAiD is considered a non-natural cause of death; therefore, the Burial and Criminal Act states that consent from the public prosecutor is required for organ donation to proceed, and a report needs to be submitted afterward for evaluation by the regional review committee.^4,41 In Belgium, MAiD is considered a natural cause of death, according to the Belgian Euthanasia Act, and does not require consent from the public prosecutor; however, similar to The Netherlands, a report needs to be sent to the federal monitoring and evaluation commission on euthanasia so they can assess whether the procedure was properly performed.⁴ In Canada, organ donation following MAiD is acceptable across provinces, but we did not locate any references describing MAiD as natural or non-natural death, nor did we find any requirements for public prosecutor follow-up.

In Canada, MAiD was enacted through Bill C-14 in 2016.^{5,6,12,29,47,48,58–60,64,65,71} Bill C-14 amended the Criminal Code, and it was later altered to allow for advance directives by Bill C-7 in 2021. In Belgium, MAiD was endorsed by the Belgian Euthanasia Act 2002.^{1,4,25,53,63,70,72} In The Netherlands, MAiD was enacted through the Dutch Euthanasia Act 2002 (Dutch Termination of Life on Request and Assisted Suicide Act).^{3,4,25,66,67,70} More details regarding this legislation and the eligibility criteria can be found in Appendix IV.

For patients who request MAiD to proceed with organ donation, they must go through a process of informed consent to authorize MAiD and, depending on the institution, patients must voluntarily express the desire for donation after being approved for MAiD before conversations about organ donation can begin. General rules for organ-donation consent, within and outside the context of MAiD, vary across the 3 countries. In Belgium, there is a presumed consent (opt out) system for organ donation.⁴ The Netherlands used an opt-in system for organ donation; however, in 2020, the donor law was changed from an opt-in system to an active donor registration system.^4,26,41 Canada has an explicit consent regime (opt in), except for the province of Nova Scotia, where a presumed consent (opt out) system was implemented in 2021¹⁰² (see Appendix IV).

In terms of practice guidelines to ensure the quality and safety of the procedures, we have identified a list of reports on protocols, guidelines, and manuals related to organ donation following MAiD that are available in the 3 countries where this procedure was permitted at the time of the literature search (see Table 2). These documents present details about processes and procedures involved in organ donation following MAiD, including safeguards for patients and health care professionals involved in MAiD provision/organ donation processes, mental health support, patients’ and health care professionals’ rights related to participation in MAiD-related activities, among others.

Table 2.

Guidelines, protocols, and manuals for medical assistance in dying and organ donation

Country	Organization/publisher	Year	Title
Belgium	Societe Belge de Transplantation	2015	Le don d’organes après l’euthanasie
Canada	Transplant Québec	2015	Enjeux éthiques liés au don d’organes en contexte d’aide médicale à mourir
	Trillium Gift of Life Network	2018	Organ and Tissue Donation Following Medical Assistance in Dying: Program Development Toolkit
	Quebec Transplant	2018	Sur le don D’organes chez un Patient qui Demande une Aide Médicale à Mourir
	CBS, CCCS, CST, and CACCN at CMAJ	2019	Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy
	BC Transplant	2020	BC Transplant Donation after MAiD Toolkit for Healthcare Workers
The Netherlands	KNMG	2014	Euthanasie en (orgaan) donatie: werkwijze bij (versie 2)
	Published at American Journal of Transplantation	2016	Organ Donation After Euthanasia: A Dutch Practical Manual
	Jaarverslag	2017	Regionale toetsingscommissies euthanasie
	Nederlandse Transplantatie Stichting	2017	Orgaandonatie na euthanasie Deel 1: Instructies voor de praktijk
	Nederlandse Transplantatie Stichting	2017	Richtlijn Orgaandonatie na euthanasie Deel 2 Achtergronden
	KNMG and KNMP	2021	Richtlijn uitvoering euthanasie en hulp bij zelfdoding
	Nederlandse Transplantatie Stichting	2021	Richtlijn Orgaandonatie na euthanasie Instructies voor de praktijk: versie 2

CACCN, Canadian Association of Critical Care Nurses; CBS, Canadian Blood Services; CCCS, Canadian Critical Care Society; CMAJ, Canadian Medical Association Journal; CST, Canadian Society of Transplantation; KNMG, Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst; KNMP, Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie; MAiD, medical assistance in dying.

In terms of the involvement of health care professionals in organ donation following MAiD, we identified that the health care professionals involved should be accountable, but not criminally liable (eg, prosecuted as first-degree murder), for participating in a MAiD provision. Bills and acts regulating MAiD are in place in different countries to ensure the protection of health care professionals and patients, and where MAiD is allowed, the professionals involved are legally protected. However, as in any other health care practice, professionals need to adhere to accepted medical practice to ensure they will not be prosecuted for other reasons (eg, medical negligence).

Ethics, dilemmas, and consensus

The combination of organ donation and MAiD provision has sparked discussion and debate regarding various ethical dilemmas involved in this procedure. We identified 75 reports that mentioned these considerations, which we divided into the following subheadings: ethical safeguards for organ donation following MAiD, eligibility criteria for organ donation and MAiD, disclosure of donors’ and recipients’ information, directed organ donation, death determination in organ donation following MAiD, and death by donation.

Ethical safeguards for organ donation following MAiD

Individuals who request MAiD are considered vulnerable and can be impacted by external influences on their personal and system beliefs.^32,41 For that reason, a number of safeguards must be in place to support and respect individual autonomy and ensure the separation of MAiD and organ donation decisions. These discussions are rooted in the fundamental ethical principles of autonomy, dignity, beneficence, non-maleficence, and distributive justice.^34,53 They include aspects related to the right of choice, separation of MAiD and organ donation discussions, pressure of vulnerable individuals, initiation of organ donation discussions, and death determination.

Some authors argued that if there is consensus that individuals have the right to make end-of-life decisions, they should also be given the opportunity to donate their organs.⁵⁰ Also, it is vital that health care professionals ensure that individuals are fully aware that they have the freedom to withdraw their request for MAiD and donation, or continue their request for MAiD and withdraw their donation request, as a means to mitigate any perceived pressure or obligation from external factors.^{32,37,41,49,53,63}

Another major ethical safeguard discussion is the separation of MAiD provision and organ donation procedures. There is a consensus in the literature that organ donation must not be discussed before the request for MAiD is granted.^{12,21,27,37,50,56,58,77,78,83,91} To respect patient autonomy, health care providers must ensure that the wish for organ donation is not the reason for choosing MAiD to avoid actual or potential conflicts of interest. The consensus identified across multiple documents was that there must be a clear separation of the conversations about organ donation and MAiD,^{4,6,8,12,25,27,39,47,49,50,57,59,72,78} and of the health care professionals involved in each procedure.^{8,12,41,49,50,85} However, some authors highlighted that separating the discussions and decisions around organ donation and MAiD can be extremely challenging as these procedures are interconnected, and the decision-making is not a linear process.^8,30,33,55

The approach for organ donation after MAiD varies in different locations. In Canada, for example, organ donation organizations in some provinces (eg, Ontario, British Columbia) recommend that all patients who request MAiD are approached and informed about the possibility of organ donation,^{12,23,29,30,32,48,49,59,77,82,87,90,91} while in other provinces (eg, Alberta, Manitoba), patients are not asked about organ donation unless they start this conversation.^87,91 In one Canadian province (Québec), most health care providers were in favor of informing patients who request MAiD about the possibility of organ donation, but they also stressed that this discussion should only occur after the MAiD request has been granted and that the discussions for both procedures should be kept separate.²¹ In the Dutch guideline, recommendations are that patients who request MAiD should initiate the discussion about organ donation,^8,21,37,74 even though Belgium and The Netherlands have organ donor registry systems (presumed consent and donor registry, respectively; see Appendix IV). Thus, some authors suggested that the physician responsible for MAiD can verify if the patient has expressed objection/intention for organ donation and then decide whether to discuss organ donation with the patient, but it is preferable that patients start this discussion.^{3,4,8,26,30,37,38,41,44,84}

Overall, authors expressed concerns that the conversation about the possibility of organ donation may pressure vulnerable patients to proceed with MAiD,^{4,12,37,56,64,77,88} cause a breach of trust with the health care professionals involved in MAiD (as the patient may feel that MAiD will only be performed if combined with organ donation),^4,56,84 and generate frustration for the patient and family if the possibility of donation is raised but cannot be granted due to the patient’s health condition.^4,49 Also, as the patient may be under extreme suffering, it may be inappropriate to discuss organ donation in some cases, and health care professionals involved in these procedures should analyze the situation on a case-by-case basis.^26,77

The dilemma of how and when to initiate conversations about organ donation with patients undergoing MAiD is challenging. Not informing patients about the possibility of donation can prevent them from exploring the opportunity to donate their organs and negatively impact their autonomy,^4,12,37 while informing them of this possibility may cause undue societal pressure for donation, and the desire to become a donor may be a driver for the MAiD request.^{4,12,37,55,77} Nevertheless, organ donation following MAiD is an emotionally charged and complex process that triggers different feelings and thoughts in patients. Patients must always be made aware that they can change their minds at any time in the process,^47,56 and questioning their own decision does not mean that the system is failing to disentangle ethical safeguards.⁸ Above all, it is imperative that the patient is the center of the process; their well-being must always be the priority, so organ donation must remain secondary to the MAiD process.^28,56,77

In the context of organ donation following MAiD, another important ethical safeguard is respect for the patient’s autonomy and wishes. One of the main principles of MAiD is to guarantee that the patient’s autonomy is respected so they can safely end their lives. In the context of organ donation, this respect is equally important when it comes to the patient’s last wishes for donation.^{5,10,12,21,28,37,40,41,43,52,53,56,62,81,82,86,91,94,95} Some authors expressed the opinion that, in places where there is existing legislation to permit this combined procedure, the patient’s wish should not be denied.^27,69 An important aspect in respecting the patient’s wish for donation is the comfort the patient gets from knowing that their death will help other people through transplantation,^{4,25,27,37,40,41,43,57,63,72,75,77,82,83,86,87,91} and for the families to know that the last wish of their loved one was granted.^25,75,87 Some authors⁷³ also stated that other ethical and logistical issues that are currently preventing patients from donating as many organs as possible (eg, death determination, directed donation, desire for MAiD at home) should be further investigated in order to respect patient wishes and autonomy. Lastly, the decision to donate organs after MAiD by a patient who has nothing to gain from it should be considered an act of altruism, and such an act should not be impeded.^{4,8,12,27,32,77,95}

Eligibility criteria for organ donation and MAiD

Some authors^30,31 expressed a concern that enabling patients who request MAiD to donate their organs could lead to an expansion of the MAiD criteria to include individuals contemplating suicide as potential donors, since these individuals tend to be mostly young and physically healthy. Also, although suicidal individuals do not currently fulfill the requirements for MAiD, with the progress of practices and updates in legislation, Buturovic^30,31 stated a more extreme fear that the same authors who are currently defending organ donation following MAiD may soon be advocating for the inclusion of individuals with suicidal ideation to be eligible for MAiD to expand the donor pool. Another author⁵⁵ stated that patients who request MAiD should be treated differently than suicidal individuals, as the motivation to die may be generated by the desire for organ donation for patients who request MAiD.

As shown in Appendix IV, the eligibility criteria for MAiD vary across countries. In Canada only individuals older than 18 years can request MAiD¹⁰³; however in Belgium¹⁰⁴ and The Netherlands,¹⁰⁵ minors (12 years or older) may also request the procedure. The possibility of MAiD for different age groups has raised discussions around whether children should also be able to request organ donation following MAiD. MAiD among children is rare. Reports suggest that only a few cases have been performed in The Netherlands,⁴ while experts anecdotally report that some cases have been performed in Belgium. The main reason for the request for MAiD among children was a terminal condition due to some type of malignancy, which is normally a contraindication to organ donation.⁴

Authors also argued that, in a context where MAiD is legal among children, if children/adolescents are able to decide to request MAiD, then they and/or their guardians may also be able to express and have their desire fulfilled for organ donation.^8,25 Authors pointed out that there is no legal impediment or categorical objection to organ donation after MAiD in children.^8,37 Although there are few publications discussing organ donation after MAiD among children and adolescents, there appeared to be consensus in the limited literature that this population can be offered the opportunity to decide to donate their organs. However, it is worth noting that all publications discussing organ donation following MAiD among children were from the same group of researchers.^4,8,25,37 This topic needs to be further discussed and explored within the scientific community.

Disclosure of donors’ and recipients’ information

With organ donation following MAiD, the donor is alive at the time of the screening and allocation processes. Because of that difference, some authors have expressed concerns regarding whether disclosing information about potential recipients (eg, if they have a match) to the MAiD patient will generate extra pressure on them.^4,26,59 Some authors reported that revealing information about potential recipients of organs from donors who request MAiD is not recommended and even illegal in some countries (eg, The Netherlands, according to the Dutch Practical Manual). This is because it conflicts with privacy laws, and it may influence the patient’s decision to proceed with MAiD if they know someone is waiting for their organs, even though they can withdraw their request for MAiD and donation, or continue their request for MAiD and withdraw their request for donation at any time.²⁶ However, a report from Canada indicated that some patients who requested MAiD and received information related to the potential recipients of their organs felt that this allowed them to focus on something positive and alleviated their suffering, as they knew they would be able to help someone.⁵⁹

Disclosing information about the donor to potential recipients has also been controversial. A concern is that potential recipients of organs recovered from donors who requested MAiD may decline acceptance of an organ if the MAiD process is against their beliefs.^12,57 The opinion regarding this topic was divided, and some authors were unsure whether recipients should be informed about the origin of the organs.^6,47,57,64 Still, it is worth noting that organs from donors who requested MAiD can only be allocated in countries where organ donation after MAiD is allowed. Some authors argued that because recipients are not informed of the donor background in general for deceased donation (eg, if the donor died by suicide or was a criminal), MAiD should follow the same rationale, as there is no evidence that organs retrieved after MAiD create additional risks to recipients.^41,71,91

Still, it is important to highlight that there are risks associated with certain conditions unrelated to the donation category (eg, MAiD or brain dead); for example, for donors with a rapidly progressive neurodegenerative disease, the risks for the recipients are still unknown, and this type of information should be disclosed to potential recipients.⁴⁹ Some authors stated that if a connection between MAiD and potential risks is discovered in the future, recipients should have this information disclosed to them.⁶⁴

Additionally, others argued that autonomy should exist bilaterally, and recipients should have the right to receive this information and refuse transplantation if they choose.^49,90 To avoid this problem, Eurotransplant, in their 2008 annual report, recommended that patient records should include whether they are willing to receive organs retrieved following MAiD.^12,26 A similar suggestion has been made in Québec, Canada.⁹¹ Nevertheless, despite the possibility that recipients could object to receiving organs retrieved after MAiD, authors mentioned that it had not been an issue in their practice so far.^56,68

Directed organ donation

Guidance for directed organ donation following MAiD varied across the literature. Directed organ donation is when a patient donates an organ directly to someone they know and who is a match. In The Netherlands and Belgium, patients who agree to organ donation following death are not usually allowed to choose which individuals receive their organs (exceptions may occur on a case-by-case basis). The unavailability of directed donation may lead patients who request MAiD to choose living donation instead to ensure their loved ones can receive their organ (eg, kidney); however, this practice may lead patients who are already under extreme suffering to go through extra procedures and distress.

In Canada, directed deceased donation is not prohibited by the legislation or by the organ donation organizations, and, depending on the province, organizations permit this practice.¹² However, current guidance states that directed organ donation following MAiD should not be offered or encouraged.⁴⁹ In a study conducted in one province in Canada, health care professionals were asked about ethical issues surrounding organ donation following MAiD.²¹ When asked about directed donation, they initially reported disagreeing with this practice, but when they were probed to think about this practice in the context of living donation, they were generally more accepting.²¹ Even so, many authors raised concerns about ensuring that the decision for directed donation is voluntary and free from any type of coercion,^12,24,47 and it is not a driver for the decision for MAiD.⁵⁵

Some of the potential risks described for the practice of directed donation included the possibility that patients who requested MAiD might feel pressured to proceed with MAiD to end their loved one’s suffering through transplantation.^{12,21,58,90,96} Or, if a positive human leukocyte antigen matching with their loved one is identified, they may feel pressured to proceed with MAiD and donation to ensure that this person will have a suitable donor.²⁶ Solutions suggested to prevent such interferences in the decisions of patients who requested MAiD included prohibiting directed donation⁵⁸; careful examination of directed donation requests on an individual basis determining whether patients would still request MAiD should donation (directed or otherwise) not be possible³²; ensuring patients feel free up to the last moment to withdraw consent for either MAiD or organ donation³²; keeping conversations about MAiD and organ donation separate; and proceeding with living donation before the MAiD procedure.^12,21,71 However, living donation prior to MAiD has been opposed by some authors, as the surgical procedures could lead to increased suffering, with only minor benefits, for patients who request MAiD, and the pressure of the living donation commitment even if they change their mind.^12,21,26,37

Death determination in organ donation following MAiD

There are controversial opinions regarding the timing of death determination and the challenges for organ donation following MAiD in terms of the dead donor rule. The discussion of death determination (both neurological and circulatory) continues to evolve in the context of organ donation, with ongoing questions about irreversibility and whether the donor is dead before organ procurement.⁵¹ Although some authors saw a major ethical difference between causing the death and then procuring the organs and causing the death through procuring the organs,¹² a view which some health care professionals seemed to support,²¹ other authors suggested that the dead donor rule should not be forsaken.

The dead donor rule stipulates that organ donation should not cause or hasten death, and that an individual must be pronounced dead before organ procurement.^{4,41,49,57,71,79,93} This has been a key principle of organ donation for decades, critical to protecting individuals by assuring that people are not killed for their organs, while keeping a firewall between what is better for the donor versus for the recipient.^{6,57,59,73,106} In general, current legislation and guidelines from Canada, Belgium, and The Netherlands follow the dead donor rule as an ethical standard in all cases of organ donation, meaning organ procurement must not begin until the patient is declared dead.^{6,23,26,49,50,79}

Similarly, in the context of organ donation following MAiD, the dead donor rule cannot be abandoned, and death needs to occur prior to the initiation of organ procurement.^6,52,65,67 However, in cases of donation following MAiD, some argued that the dead donor rule may be prohibitive if the individual wants a peaceful death while optimizing the process of donating any potentially viable organs; some authors questioned why access to the dual procedure would be restricted on the grounds of the dead donor rule if it is the patient’s wish to die and to donate.^6,80 Although the dying process is quicker in organ donation following MAiD than in the other categories of circulatory death, there is still a risk of reduced quality of organs due to prolonged warm ischemia time that occurs during the dying process. If the dead donor rule were abandoned, it would eliminate this risk. As a result, a number of authors raised the question of whether the dead donor rule should be applied in the context of organ donation following MAiD, given that individuals are making informed and autonomous decisions about their end-of-life care.^{12,58,61,71,73,79,91}

In the MAiD context, death is determined using circulatory and respiratory criteria, but the absence of visible respiration and palpable pulse is not enough to determine death in the context of organ donation.^23,65 Usually, at least one of the following criteria must be used to determine death for organ donation following MAiD: absence of pulse, measured using arterial line monitoring^23,40,65,105; carotid perfusion ultrasound^23,65; doppler monitoring^23,65; aortic valve ultrasound^23,65 and/or isoelectric electrocardiography.^23,65 A 5-minute “no-touch period” is required to determine that the loss of circulation following medication administration is permanent.^{40,41,43,44,65,66,107} Depending on the country, 2 or 3 clinicians (either physician or nurse practitioner) are required to determine death.^63,65

Some authors offer alternative solutions to reduce the time of warm ischemia, such as changing the definition of death,⁵⁸ abandoning the no-touch time,^4,59,62,91 or introducing potassium chloride in the MAiD administration of medication to hasten death.⁵⁹ In order for any changes to occur that directly impact the compliance of the dead donor rule, there need to be changes in the organ donation legislation and clear guidelines in place regarding the determination of death to ensure organ procurement can begin as soon as possible.^49,52,58

Death by donation

A possible solution discussed in the literature for abandoning the dead donor rule is death by donation. Death by donation, also known as organ donation euthanasia, is when an individual makes the informed decision to receive anesthesia and have their organs procured, ultimately resulting in death. It is a procedure not currently allowed in any jurisdiction and has generated many controversial discussions in the literature.

The primary ethical question posed regarding death by donation is whether individuals should be given the option to provide informed consent to have their organs procured prior to death.^{6,52,73,80,81,91} Compounding this issue is that, for some patients who request MAiD, relatives may insist on witnessing the death before the transfer of the body to the operating room.²⁶ Authors posited that, if individuals accept MAiD as being ethical, perhaps death by donation should be considered acceptable as well because the reasons for the dead donor rule would become irrelevant in that situation.^21,64,73,74 There were also discussions in the literature that the practice of death by donation may improve transparency in organ donation practices,⁶¹ and it would not harm the patient more than traditional organ donation after death by MAiD.⁷⁴

Authors suggested that death by donation may increase the number and quality of organs that an individual could donate, as the procedure would decrease the ischemic time, allowing for better quality and number of organs donated^{4,21,30,52,58,62,73,79}; protect patient autonomy^8,73,74; and, as patients want to donate their organs, these organs could be procured similarly to brain-dead patients.⁶ Despite concerns from some health care providers and the public that death by donation may become a reality,⁵⁵ other health care providers questioned whether there is a moral difference between organ donation after MAiD and death by donation, and that in order to preserve respect and autonomy, patients may be provided with the right to choose how they want to die.^12,21 Some of the counterarguments for providing death by donation were that it would breach the dead donor rule,^50,52 fear of the patient “waking up” during organ procurement,⁵² and decreased public trust in the organ donation system, resulting in fewer donors in general.^74,91 Authors also argued that another potential challenge would be the change in roles for health care professionals. In traditional MAiD, the physician (or nurse practitioner in the Canadian context) who analyzes the due diligence requirements is the one legally responsible for the MAiD provision, while in death by donation, the surgeon would be responsible, which could generate debates among surgeons and the operating room team.⁷⁴

Despite increasing reports of individuals requesting death by donation because it would allow them to donate more organs with increased quality,^26,37,74,106 there are no reports of this practice, as it goes against the current legislation in the countries included in this review (Canada, The Netherlands, and Belgium). If at some point death by donation becomes a possibility, amendments in the current legislation—including criminal codes, as this practice currently could be classified as homicide in some countries—would be needed so that health care professionals could practice safely and patients would be protected.^6,37,52,79

Lastly, cost savings to the health care system was touted as an additional benefit to permitting death by donation⁶⁴; however, cost savings and increased organs for transplantation should not be the rationale for death by donation. Instead, there should be a focus on respecting patient autonomy and their end-of-life wishes.^8,12,94

Consent for MAiD and organ donation

The discussions around consent and objection to organ donation after MAiD are numerous and include aspects related to confidentiality of MAiD procedures, consent to MAiD and to organ donation, and deterioration of the patient’s condition. We found this reported in 44 references. As previously mentioned, the requirements for a patient to be eligible for MAiD vary across the countries in which this procedure is allowed (Appendix IV), but there is a consensus that the patient must be experiencing unbearable and irreversible suffering, be mentally competent, request the procedure voluntarily, and give informed consent to the procedure.

Consent is an important step of the MAiD process, particularly when combined with organ donation. Some authors highlighted that, besides the need for informed consent at the beginning of the MAiD process, patients may also need to reconfirm consent right before the administration of the lethal drugs.^8,31,99 Also, if the patient’s condition deteriorates in the days preceding the procedure, some authors suggested that new medical evaluations may be needed,²⁴ while others recommended that this conversation should be held beforehand with the patient. Also, some authors commented that, if acute deterioration happens at home, organ donation should not be performed¹⁰; however, if deterioration happens in the hospital, then organ donation may proceed. If the patient becomes unconscious, MAiD and organ donation should not be performed, as the patient is not under unbearable suffering anymore.⁴⁹

Some authors also discussed the importance of confidentiality in the MAiD process. Discussions were around the right to confidentiality related to end-of-life care, meaning that the information cannot be disclosed to others, including family members, without the patient’s expressed consent.^{12,34,62,65,77} The consent to organ donation is an important difference between patients who request MAiD compared with organ donors of other types of deceased donation, as patients who request MAiD give first-person consent to organ donation.^{4,6,12,21,23,25,34,48,49,51,58,59,65,68,71,82,91} First-person consent is usually perceived as the best-possible scenario, as it allows for direct expression of the patient’s preferences regarding organ donation, rather than relying on the donor registry and family members, or other substitute decision-makers, to express these preferences on the patient’s behalf.

Besides the discussions regarding the separation of consent between the MAiD procedure and organ donation, one author expressed concern that MAiD procedures might be delayed to optimize timing for the recipient to receive the organ based on end-stage of the disease (eg, in directed donation) or logistic aspects related to transplantation process.⁹⁰ However no reports of this type of situation were found in the literature.

Public perceptions

The public perception of the complexities and controversial ethical issues involving organ donation following MAiD is an important aspect that can influence its social acceptance, as well as support and/or shape policies in this area. We found this discussion in 48 references. There was an overall concern that the possibility of organ donation after MAiD may motivate patients to request MAiD so they can donate their organs as a result of social pressure to proceed with donation.^{1,4,8,12,21,30,36,37,39,47,48,51,55,58,59,62,64,71,73,74,76,78,80,87,88,90–92,94} Some patients may feel they are a burden to their family and friends, and feel motivated to undergo MAiD to relieve this burden.^12,30 Therefore, health care professionals should be attentive to potential indicators that the patient may somehow be feeling pressured to proceed with MAiD or MAiD and organ donation.^{8,12,26,34,40,51,90,92,94}

Public perception may influence legislation, policy, and practice, and it is an important aspect to consider when discussing controversial topics, such as organ donation following MAiD. There is the potential that having the option of requesting organ donation following MAiD may either increase or decrease the public trust in these procedures.⁵¹ This is because deceased organ donation, either from brain-dead donors or from donors with a circulatory determination of death, is already a socially accepted practice rooted in public trust in the health care system.^12,21,59,90 However a patient requesting to end their life through MAiD, regardless of whether it is followed by organ donation, remains a contentious, ethically charged issue in the public domain.⁵⁵ Thus, it must be clear to the public that policies and guidelines are in place to protect individuals who choose one or both of these procedures, particularly for vulnerable populations, such as minors.^25,57,80

Additionally, the media can influence public perception positively by increasing acceptance of organ donation following MAiD by publishing MAiD patients’ stories on how organ donation added meaning to their end-of-life care by fulfilling their last wishes.⁴ Media can also influence public perception negatively when sensationalized ideas are presented, such as those suggesting that people would be killed for their organs, creating challenges in gaining and maintaining public trust.^41,76 If the public perception is that health care providers are attempting to coerce patients choosing MAiD to consider organ donation, thus disregarding the principle of autonomy, general organ donation consent rates may decline.¹²

To overcome legal and ethical barriers, public trust and awareness are essential^{39,40,51,57,80,88}; however, this should be constructed gradually and cautiously,^40,51,88 as public trust is easier to break than to repair.⁵⁹ The general public must have confidence that health care providers have ethical safeguards in place to establish clear boundaries to separate requests for MAiD and organ donation, as well as to make objective decisions.⁴ Finally, there must be no question that individuals choosing MAiD with or without organ donation will receive the same care or treatment as any other patient.⁴

Although organ donation following MAiD provides the opportunity for first-person, fully informed consent, which may reduce the potential for the family to object to organ donation, there is still the possibility that family members may have different perceptions related to this process. When there is a patient’s expressed consent, if the patient requesting MAiD agrees, families should be provided with information to ensure they understand the implications of organ donation following MAiD.^{6,12,26,40,41} For example, families may not have the opportunity to spend a significant amount of time with the patient following their death because it is important to get the patient to the operating room as soon as possible for organ procurement. Therefore, it is prudent to encourage family members to express their final words and goodbyes prior to MAiD drug administration.^{6,12,26,40,41} Despite the impact on the end-of-life experience, family members have anecdotally reported that organ donation following the MAiD process was a positive experience, despite the short time they could spend with their loved one after the death.⁸⁶

Family members also reported being pleased that their loved one had their final wish to donate their organs granted, and they were hopeful that more patients would have the opportunity to donate their organs if they chose MAiD.^8,27,75 In The Netherlands, where MAiD among children has occurred, parents reported that the option to support organ donation for their child would have resulted in positive feelings for them even after the child’s death. Still, it is important to note that no case of pediatric organ donation after MAiD has been reported.²⁵

Finally, reports indicated that patients who requested MAiD were aware of the additional challenges of organ donation, yet they usually found the opportunity to help others through a last altruistic gift more important.^37,41,82 As expressed by one patient in a study⁸²:

It has always been a parallel thought process for me. I thought the knowledge of having full autonomy by way of MAiD was comforting, but, when the possibility of organ donation was added to it, the sense of elation is the only appropriate word for me. It is so exciting to know that I have the potential to alleviate the suffering of someone on a waitlist. ^(p.4)

The capacity to fulfill the last wish of these patients to dimmish their suffering should be the main, and only, reason to advocate for organ donation following MAiD.³⁷

Discussion

In this first part of the 2-part review on organ donation following MAiD, we presented a summary of 89 reports published that discussed variations in MAiD definitions, legislation, and practice worldwide; provided an overview of the current ethical discussions and consensus in the field; explored differences in consent for MAiD and organ donation following MAiD; and presented details on the public, patient, and family perceptions. The results presented in this review highlighted the summary of findings from the literature and are independent of the authors’ opinions on this topic. The availability of controlled organ donation following MAiD has raised many discussions around how to ensure ethical acceptable procedures for patients opting for this process while respecting the existing legislation around both procedures.⁴ Still, the existing evidence highlighted that when patients requesting MAiD wish to donate their organs, efforts should be made to honor this request, as it can help fulfill their last wishes, diminish their suffering, and increase the availability of organs for donation.

Organ donation following MAiD was legal in Canada, Belgium, and The Netherlands at the time of our search, and our findings highlighted the different legislations regulating both procedures in these countries. The eligibility criteria for MAiD have raised concerns, such as whether minors eligible for MAiD (eg, in The Netherlands and Belgium) should also be allowed to opt for organ donation. The limited literature on this topic seemed to agree that there is no categorical objection to allowing this process in children, although it has not been performed yet.^8,37 Additionally, as organ donation following MAiD is still a relatively new procedure, guidelines need to be routinely updated to align with legislation and ensure the safety and protection of patients and health care professionals.

Despite the legal considerations, studies included in our review highlighted evidence around the many ethical debates involved in organ donation following MAiD. The determination of death for organ donation, for both neurological and circulatory determination of death, continues to evolve.⁵¹ Studies discussed the importance of death determination for organ donors in the MAiD context where the patient desires to die, for example, if the dead donor rule should be abandoned for organ donors who request MAiD. Possible solutions have been suggested to improve the autonomy of patients who request MAiD and increase the quality of organs for donation, such as by performing death by donation; however, despite being present in the literature, these are not acceptable medical practices.

Additionally, our findings highlighted the importance of public perception of organ donation following MAiD and that it can influence legislation, policy, and practice. Therefore, organizations should proceed with caution, as the availability of this process may increase or decrease the public trust in organ donation, MAiD, or both.⁵¹

Despite the many debates around this process, the family members reported being pleased that their loved one had their final wish granted by donating their organs.^8,27,75 For patients who request MAiD, the availability of organ donation can help diminish their suffering at the end-of-life through a last altruistic act.^37,41,82 Finally, patients who request MAiD should be provided with the opportunity to donate their organs, and should be aware that they can change their mind at any point in the process and withdraw their request for either procedure. There must be no question that these individuals will receive the same care or treatment as any other patient.⁴ The ability to support the autonomy and fulfill the last wishes of patients who request MAiD should be the main reason to advocate for organ donation following MAiD.

Limitations

Due to the scope of this work, this review does not bring direct solutions to practice, nor does it give a clear direction to clinicians in the field. Instead, our broad scope aims to provide an overall map of the literature to inform and guide researchers and other stakeholders in organ donation following MAiD about the current state of the literature on this topic. Another limitation is that some of the discussions presented (eg, related to MAiD among children) were from the same group of researchers, which may denote a limited view of the topic. Also, the existing regulations and guidelines provided divergent orientations to clinical practice, which can add to the complexity of organ donation following MAiD.

Conclusion

MAiD is a controversial topic worldwide, and the possibility of organ donation following MAiD has raised many concerns about ethical safeguards and regulations that should be in place to ensure the safety and rigor of this process. Although those debates are important for clinical practice, there was no consensus in the existing literature, and this will need to be further explored. The existing evidence also highlights that there are different regulations in place to establish the eligibility criteria for patients who want to have MAiD, organ donation, or both, as well as to ensure that health care professionals are not criminally liable for the death of these patients. However, the guidelines for clinical practice were not clear. In some aspects (eg, directed organ donation), differences were found between regulations and clinical guidelines, which need to be clarified.

The major debates concern the eligibility criteria for MAiD, disclosure of donors’ and recipients’ information, directed organ donation, death determination, ethical safeguards, consent for MAiD and organ donation, and public perceptions. Despite the many ethical and legal concerns related to organ donation following MAiD, this option has been shown to positively impact the end-of-life experience of donors who requested MAiD and their families, and to help diminish the patient’s suffering. It is, therefore, a valid avenue for patients who request MAiD. Lastly, the results presented in this review highlight the summary of findings from the literature and are independent of the authors’ opinions on this topic.

Implications for research and practice

This is the first review, to the best of our knowledge, highlighting the main ethical and legal discussions regarding organ donation following MAiD. In this review, we stated the main legislation regulating organ donation following MAiD in countries where this procedure is allowed, and identified the main ethical debates regarding safeguards that should be in place to protect patients and families. These results highlight the legal aspects of how deceased organ donation practices are taking place worldwide. Findings from this review can be used to guide researchers and clinicians about the next steps needed to improve the practice of organ donation following MAiD.

Acknowledgments

Information specialists, Robin Featherstone, for developing and executing the main electronic search strategies, and Amanda Ross-White, for reviewing the search strategy.

Funding

This work was financially supported by Canadian Blood Services. Canadian Blood Services receives funding from the provincial and territorial ministries of health and the federal government, through Health Canada. Canadian Blood Services is a national, not‐for-profit charitable organization that manages the supply of blood and blood products in all provinces and territories in Canada (with the exception of Québec) and oversees the Canadian Blood Services Stem Cell Registry. In 2008, Canadian Blood Services became responsible for national activities related to organ and tissue donation and transplantation, which includes national system development and operation of interprovincial organ sharing programs. Canadian Blood Services is not responsible for the management or funding of any Canadian organ donation organization or transplant program. The views expressed herein do not necessarily represent the views of the federal, provincial, or territorial governments.

Author contributions

All authors contributed to designing the research, collecting the data, performing the analysis, and writing the manuscript.

Supplementary Material

srx-22-157-s001.pdf ^{(814.9KB, pdf)}

Appendix I: Search strategy

Ovid MEDLINE(R) ALL 1946 to December 03, 2021

Search conducted: December 4, 2021

Search	Query	Records retrieved
1	Euthanasia	8093
2	Euthanasia, Active	2209
3	Euthanasia, Active, Voluntary	1795
4	Euthanasia, Passive	5984
5	((accompanied or assist*) adj2 (death* or dying or suicide*)).tw,kf.	5504
6	euthanasia*.tw,kf.	23,040
7	“medical assistance in dying”.tw,kf.	277
8	planned death.tw,kf.	18
9	(physician hastened adj2 (death* or dying or suicide*)).tw,kf.	18
10	“right to die”.tw,kf.	967
11	or/1-10 [Set 1: Medical assistance in dying]	30,985
12	Donor Selection	3638
13	exp Organ Transplantation	223,312
14	“Tissue and Organ Harvesting”	9589
15	exp “Tissue and Organ Procurement”	22798
16	exp Tissue Transplantation	195,683
17	exp Tissue Donors	78,406
18	exp Transplant Recipients	5631
19	(allocate* adj2 (organ$1 or tissue*)).tw,kf.	1831
20	((body or organ$1 or tissue*) adj2 (donor* or donation*)).tw,kf.	21,129
21	((cardiac or heart$1 or heart-lung or hepatic or intestin$ or kidney$1 or kidney-pancreas or liver$1 or lung$1 or lung-heart or multiorgan or organ$1 or pancreas or renal or thoracic or tissue$1) adj2 transplant*).tw,kf.	237,952
22	dead donor rule*.tw,kf	163
23	deceased donor*.tw,kf	6836
24	“donation after circulatory death”.tw,kf.	990
25	(donor adj2 (exclu* or select* or screen*)).tw,kf.	4756
26	((donor* or donation*) adj3 non heart beating).tw,kf	1174
27	living donor*.tw,kf.	14,282
28	(organ$1 adj2 (harvest* or procur* or retriev* or scarc*)).tw,kf.	6070
29	(tissue adj2 (harvest* or procur* or retriev*)).tw,kf.	3591
30	or/12-29 [Set 2: Organ donation]	481,655
31	and/11,30 [Sets 1 & 2]	1207
32	(exp animals/ or exp animal experimentation/ or exp models animal/ or exp vertebrates/) not (exp humans/ or exp human experimentation/)	4,926,229
33	((in-data-review or in-process or publisher or pubmed-not-medline).st. and (animal* or beagle* or cat or cats or chicken or chickens or dog or dogs or fish or hamster or hamsters or horse or horses or mouse or mice or nonhuman* or non human* or pig or pigs or porcine or rabbit or rabbit or raccoon or raccoons or racehorse or racehorses or rat or rats or rodent* or sheep).ti,kf.) not (adults or children or human or humans or infants or patient or patients or people or seniors).ti,kf	138,532
34	32 or 33 [Animal filter]	5,064,761
35	31 not 34 [Exclude animal studies]	1086
36	remove duplicates from 35 [MEDLINE results for export]	1086

Ovid Embase Classic+Embase 1947 to 2021 December 03

Search conducted: December 4, 2021

Search	Query	Records retrieved
1	active euthanasia	1881
2	euthanasia	17,480
3	passive euthanasia	4918
4	voluntary euthanasia	1464
5	((accompanied or assist*) adj2 (death* or dying or suicide*)).tw,kw.	6164
6	euthanasia*.tw,kw.	16,472
7	“medical assistance in dying”.tw,kw.	321
8	planned death.tw,kw.	22
9	(physician hastened adj2 (death* or dying or suicide*)).tw,kw.	18
10	“right to die”.tw,kw.	1063
11	or/1-10 [Set 1: Medical assistance in dying]	31,615
12	donor selection	6429
13	graft recipient	62,586
14	exp organ donor	42,213
15	exp organ transplantation	436,011
16	exp tissue transplantation	567,581
17	(allocat* adj2 (organ$1 or tissue*)).tw,kw.	2783
18	((body or organ$1 or tissue*) adj2 (donor* or donation*)).tw,kw.	31,585
19	((cardiac or heart$1 or heart-lung or hepatic or intestin$ or kidney$1 or kidney-pancreas or liver$1 or lung$1 or lung-heart or multiorgan or organ$1 or pancreas or renal or thoracic or tissue$1) adj2 transplant*).tw,kw.	379,242
20	dead donor rule*.tw,kw.	180
21	deceased donor*.tw,kw.	16,069
22	“donation after circulatory death”.tw,kw.	1707
23	(donor adj2 (exclu* or select* or screen*)).tw,kw.	8627
24	((donor* or donation*) adj3 non heart beating).tw,kw.	1627
25	living donor*.tw,kw.	26,404
26	(organ$1 adj2 (harvest* or procur* or retriev* or scarc*)).tw,kw.	8989
27.	(tissue adj2 (harvest* or procur* or retriev*)).tw,kw.	6189
28	or/12-27 [Set 2: Organ donation]	1,073,924
29	and/11,28 [Sets 1 & 2]	1040
30	(exp animals/ or exp animal experiment/ or exp animal experimentation/ or exp models animal/ or nonhuman/ or exp vertebrate/ or exp vertebrates/) not (exp humans/ or exp human experiment/ or exp human experimentation/)	7,593,253
31	((animal* or beagle* or cat or cats or chicken or chickens or dog or dogs or fish or hamster or hamsters or horse or horses or mouse or mice or nonhuman* or non human* or pig or pigs or porcine or rabbit or rabbit or raccoon or raccoons or racehorse or racehorses or rat or rats or rodent* or sheep) not (adults or children or human or humans or infants or patient or patients or people or seniors)).ti.	2,503,475
32	30 or 31 [Animal filter]	7,857,716
33	29 not 32 [Exclude animal studies]	607
34	remove duplicates from 33 [Embase results for export]	595

Ovid APA PsycINFO 1806 to November Week 5 2021

Search conducted: December 4, 2021

Search	Query	Records retrieved
1	Assisted Suicide	1187
2	Euthanasia	1707
3	((accompanied or assist*) adj2 (death* or dying or suicide*)).ti,ab.	1783
4	euthanasia*.ti,ab.	2161
5	“medical assistance in dying”.ti,ab.	63
	planned death.ti,ab.	5
7	(physician hastened adj2 (death* or dying or suicide*)).ti,ab.	6
8	“right to die”.ti,ab.	227
9	or/1-8 [Set 1: Medical assistance in dying]	3651
10	exp Organ Transplantation	5023
11	(allocat* adj2 (organ$1 or tissue*)).ti,ab.	53
12	((body or organ$1 or tissue*) adj2 (donor* or donation*)).ti,ab.	1379
13	((cardiac or heart$1 or heart-lung or hepatic or intestin$ or kidney$1 or kidney-pancreas or liver$1 or lung$1 or lung-heart or multiorgan or organ$1 or pancreas or renal or thoracic or tissue$1) adj2 transplant*).ti,ab.	3195
14.	dead donor rule*.ti,ab.	30
15	deceased donor*.ti,ab.	88
16	“donation after circulatory death”.ti,ab.	12
17	(donor adj2 (exclu* or select* or screen*)).ti,ab.	54
18	((donor* or donation*) adj3 non heart beating).ti,ab.	13
19	living donor*.ti,ab.	170
20	(organ$1 adj2 (harvest* or procur* or retriev* or scarc*)).ti,ab.	221
21	(tissue adj2 (harvest* or procur* or retriev*)).ti,ab.	74
22	or/10-21 [Set 2: Organ donation]	6344
23	and/9,22 [Sets 1 & 2]	55
24	remove duplicates from 23 [PsycINFO results for export]	55

Web of Science Core Collection: Science Citation Index Expanded (SCI-EXPANDED) --1900-present; Social Sciences Citation Index (SSCI) --1900-present; Arts & Humanities Citation Index (A&HCI) --1975-present; Conference Proceedings Citation Index- Science (CPCI-S) --1990-present; Conference Proceedings Citation Index- Social Science & Humanities (CPCI-SSH) --1990-present

Search conducted: December 4, 2021

Search	Query	Records retrieved
1	TS=(((accompanied OR assist*) NEAR/2 (death* OR dying OR suicide*) ) OR euthanasia* OR “medical assistance in dying” OR “planned death” OR (“physician hastened” NEAR/2 (death* or dying or suicide*) ) OR “right to die”) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years	18,914
2	TS=((allocat* NEAR/2 (organ OR organs OR tissue*) ) OR ((body OR organ OR organs OR tissue*) NEAR/2 (donor* OR donation*) ) OR ((cardiac OR heart* OR hepatic OR intestin* OR kidney* OR liver* OR lung* OR multiorgan OR organ OR organs OR pancrea* OR renal OR thoracic OR tissue*) NEAR/2 transplant*) OR “dead donor rule” OR “dead donor rules” OR “deceased donor” OR “deceased donors” OR “donation after circulatory death” OR (donor NEAR/2 (exclu* OR select* OR screen*) ) OR ((donor* OR donation*) NEAR/3 “non heart beating”) OR “living donor” OR “living donors” OR ((organ OR organs) NEAR/2 (harvest* OR procur* OR retriev* OR scarc*) ) OR (tissue NEAR/2 (harvest* OR procur* OR retriev*) )) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years	358,953
3	#1 AND #2 Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years	350
4	TI=((animal* OR beagle* OR cat OR cats OR chicken OR chickens OR dog OR dogs OR feline OR fish OR hamster OR hamsters OR horse OR horses OR mouse OR mice OR nonhuman* OR “non human” OR “non humans” OR pig OR pigs OR porcine OR rabbit OR rabbit OR raccoon OR raccoons OR racehorse OR racehorses OR rat OR rats OR rodent* OR sheep) NOT (adults OR children OR human OR humans OR infants OR patient OR patients OR people OR seniors) ) OR AB=((animal* OR beagle* OR cat OR cats OR chicken OR chickens OR dog OR dogs OR feline OR fish OR hamster OR hamsters OR horse OR horses OR mouse OR mice OR nonhuman* OR “non human” OR “non humans” OR pig OR pigs OR porcine OR rabbit OR rabbit OR raccoon OR raccoons OR racehorse OR racehorses OR rat OR rats OR rodent* OR sheep) NOT (adults OR children OR human OR humans OR infants OR patient OR patients OR people OR seniors) ) Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years	4,233,628
5	#3 NOT #4 Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years	246

CINAHL via EBSCOhost – 1981-present

Search conducted: December 4, 2021

Search	Query	Records retrieved
1	(MH “Euthanasia+“)	8140
2	(MH “Suicide, Assisted”)	3864
3	TI ((accompanied OR assist*) N2 (death* OR dying OR suicide*)) OR AB ((accompanied OR assist*) N2 (death* OR dying OR suicide*))	3276
4	TI euthanasia* OR AB euthanasia*	2950
5	TI “medical assistance in dying” OR AB “medical assistance in dying”	228
6	TI “planned death” OR AB “planned death”	3
7	TI (“physician hastened” N2 (death* OR dying OR suicide*)) OR AB (“physician hastened” N2 (death* OR dying OR suicide*))	14
8	TI “right to die” OR AB “right to die”	321
9	S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8	12,360
10	(MH “Organ Donation”)	172
11	(MH “Organ Procurement+“)	7364
12	(MH “Organ Transplantation+“)	37,392
13	(MH “Tissue and Organ Harvesting”)	1989
14	(MH “Tissue Transplantation+“)	18,624
15	(MH “Transplant Donors+“)	8962
16	(MH “Transplant Recipients”)	4733
17	TI (allocat* N2 (organ OR organs OR tissue*)) OR AB (allocat* N2 (organ OR organs OR tissue*))	284
18	TI ((body OR organ OR organs OR tissue*) N2 (donor* or donation*)) OR AB ((body OR organ OR organs OR tissue*) N2 (donor* or donation*))	5794
19	TI ((cardiac OR heart* OR hepatic OR intestine* OR kidney* OR liver* OR lung* OR multiorgan OR organ OR organs OR pancreas OR renal OR thoracic OR tissue*) N2 transplant*) OR AB ((cardiac OR heart* OR hepatic OR intestine* OR kidney* OR liver* OR lung* OR multiorgan OR organ OR organs OR pancreas OR renal OR thoracic OR tissue*) N2 transplant*)	33,230
20	TI (“dead donor rule” OR “dead donor rules”) OR AB (“dead donor rule” OR “dead donor rules”)	93
21	TI (“deceased donor” OR “deceased donors”) OR AB (“deceased donor” OR “deceased donors”)	935
22	TI “donation after circulatory death” OR AB “donation after circulatory death”	168
23	TI (donor N2 (exclu* OR select* OR screen*)) OR AB (donor N2 (exclu* OR select* OR screen*))	1403
24	TI ((donor* OR donation*) N3 “non heart beating”) OR AB ((donor* OR donation*) N3 “non heart beating”)	117
25	TI (“living donor” OR “living donors”) OR AB (“living donor” OR “living donors”)	1610
26	TI ((organ OR organs) N2 (harvest* OR procur* OR retriev* OR scarc*)) OR AB ((organ OR organs) N2 (harvest* OR procur* OR retriev* OR scarc*))	1326
27	TI (tissue N2 (harvest* OR procur* OR retriev*)) OR AB (tissue N2 (harvest* OR procur* OR retriev*))	1049
28	S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27	72,533
29	S9 AND S28	345
30	(MH “Animals+“) NOT (MH “Human”)	89,152
31	TI ((animal* OR beagle* OR cat OR cats OR chicken OR chickens OR dog OR dogs OR feline OR fish OR hamster OR hamsters OR horse OR horses OR mouse OR mice OR nonhuman* OR “non human” OR “non humans” OR pig OR pigs OR porcine OR rabbit OR rabbit OR raccoon OR raccoons OR racehorse OR racehorses OR rat OR rats OR rodent* OR sheep) NOT (adults OR children OR human OR humans OR infants OR patient OR patients OR people OR seniors)) OR AB ((animal* OR beagle* OR cat OR cats OR chicken OR chickens OR dog OR dogs OR feline OR fish OR hamster OR hamsters OR horse OR horses OR mouse OR mice OR nonhuman* OR “non human” OR “non humans” OR pig OR pigs OR porcine OR rabbit OR rabbit OR raccoon OR raccoons OR racehorse OR racehorses OR rat OR rats OR rodent* OR sheep) NOT (adults OR children OR human OR humans OR infants OR patient OR patients OR people OR seniors))	164,201
32	S30 OR S31	222,239
33	S29 NOT S32	325

Academic Search Complete via EBSCOhost – 1887-present

Search conducted: December 4, 2021

Search	Query	Records retrieved
1	TI ((accompanied OR assist*) N2 (death* OR dying OR suicide*)) OR AB ((accompanied OR assist*) N2 (death* OR dying OR suicide*))	6723
2	TI euthanasia* OR AB euthanasia*	8956
3	TI “medical assistance in dying” OR AB “medical assistance in dying”	216
4	TI “planned death” OR AB “planned death”	19
5	TI (“physician hastened” N2 (death* OR dying OR suicide*)) OR AB (“physician hastened” N2 (death* OR dying OR suicide*))	8
6	TI “right to die” OR AB “right to die”	1099
7	TI (allocat* N2 (organ OR organs OR tissue*)) OR AB (allocat* N2 (organ OR organs OR tissue*))	1239
8	TI ((body OR organ OR organs OR tissue*) N2 (donor* or donation*)) OR AB ((body OR organ OR organs OR tissue*) N2 (donor* or donation*))	12,675
9	TI ((cardiac OR heart* OR hepatic OR intestine* OR kidney* OR liver* OR lung* OR multiorgan OR organ OR organs OR pancreas OR renal OR thoracic OR tissue*) N2 transplant*) OR AB ((cardiac OR heart* OR hepatic OR intestine* OR kidney* OR liver* OR lung* OR multiorgan OR organ OR organs OR pancreas OR renal OR thoracic OR tissue*) N2 transplant*)	112,969
10	TI (“dead donor rule” OR “dead donor rules”) OR AB (“dead donor rule” OR “dead donor rules”)	123
11	TI (“deceased donor” OR “deceased donors”) OR AB (“deceased donor” OR “deceased donors”)	4166
12	TI “donation after circulatory death” OR AB “donation after circulatory death”	565
13	TI (donor N2 (exclu* OR select* OR screen*)) OR AB (donor N2 (exclu* OR select* OR screen*))	5110
14	TI ((donor* OR donation*) N3 “non heart beating”) OR AB ((donor* OR donation*) N3 “non heart beating”)	546
15	TI (“living donor” OR “living donors”) OR AB (“living donor” OR “living donors”)	7236
16	TI ((organ OR organs) N2 (harvest* OR procur* OR retriev* OR scarc*)) OR AB ((organ OR organs) N2 (harvest* OR procur* OR retriev* OR scarc*))	3134
17	TI (tissue N2 (harvest* OR procur* OR retriev*)) OR AB (tissue N2 (harvest* OR procur* OR retriev*))	3272
18	TI ((animal* OR beagle* OR cat OR cats OR chicken OR chickens OR dog OR dogs OR feline OR fish OR hamster OR hamsters OR horse OR horses OR mouse OR mice OR nonhuman* OR “non human” OR “non humans” OR pig OR pigs OR porcine OR rabbit OR rabbit OR raccoon OR raccoons OR racehorse OR racehorses OR rat OR rats OR rodent* OR sheep) NOT (adults OR children OR human OR humans OR infants OR patient OR patients OR people OR seniors)) OR AB ((animal* OR beagle* OR cat OR cats OR chicken OR chickens OR dog OR dogs OR feline OR fish OR hamster OR hamsters OR horse OR horses OR mouse OR mice OR nonhuman* OR “non human” OR “non humans” OR pig OR pigs OR porcine OR rabbit OR rabbit OR raccoon OR raccoons OR racehorse OR racehorses OR rat OR rats OR rodent* OR sheep) NOT (adults OR children OR human OR humans OR infants OR patient OR patients OR people OR seniors))	1,613,389
19	S1 OR S2 OR S3 OR S4 OR S5 OR S6	14,748
20	S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17	129,454
21	S19 AND S20	211
22	S21 NOT S18	165

Appendix II: Characteristics of included sources

Author, year	Language	Country	Type of publication	Aim	Focus	Design adopted	Origin
Abdo,36 2014	Dutch	The Netherlands	Article	Warning for the practice of ODE	The fact that ODE should not be used to reduce the transplant waiting list	Discussion paper	Database search
Allard et al.,21 2021	English	Canada	Report of empirical research	To explore Québec professionals’ perspectives on the ethical issues related to organ donation after MAiD	Ethical aspects	Qualitative research	Database search
Allard & Fortin,12 2017	English	Canada	Exploratory discussion	To look at relevant policies in other countries and examine the ethical issues associated with controlled donation after cardiac death in conscious patients who choose to die	Relevant policies	Discussion paper	Database search
Andersen,73 2021	English	Denmark	Discussion paper	To discuss key reasons put forward in favor of permitting ODE to justify a more far‐reaching suggestion for regulation, permitting people to become living vital organ donors even when they are not about to die for other reasons	ODE, heart donation, dead donor rule	Discussion paper	Database search
Baines & Jindal,22 2017	English	USA	Letter to the editor	To highlight missing psychosocial elements from the Dutch Practical Manual	Ethical aspects	Discussion paper	Database search
Ball et al.,6 2018	English	USA	Editorial	To discuss the challenges associated with OD following MAiD	Ethical aspects	Discussion paper	Database search
Ball et al.,5 2020	English	Canada	Letter to the editor	To discuss results from a cohort study on OD after MAiD in 3 Canadian provincial organ donation organizations	To present some possible statistics of OD after MAiD in Canada	Historical cohort study	Database search
BC Transplant; Organ Donation and Hospital Development,23 2020	English	Canada	Institutional report	To present a donation after MAiD toolkit for health care workers	Procedural aspects of OD following MAiD	Manual	Database search
Bollen et al.,37 2019	Dutch	The Netherlands	Journal article	An in-depth discussion of the legal aspects of OD after euthanasia in Belgium	The legal certainty that is provided with the relevant legislation and the risks that come from it	Discussion paper	Database search
Bollen et al.,3 2015	English	The Netherlands	Conference abstract	To introduce the Dutch Act on Euthanasia and OD	Exploratory discussion	Discussion paper	Database search
Bollen et al.,26 2016	English	The Netherlands	Exploratory discussion	To discuss the operational aspects of the Dutch Manual	Operational aspects	Discussion paper	Database search
Bollen et al.,4 2016	English	Belgium and The Netherlands	Ethical and legal discussion	To explore the legal and ethical requirements and boundaries of OD after euthanasia in Belgium and The Netherlands	Ethical and legal discussion	Discussion paper	Database search
Bollen, et al.,24 2016	English	The Netherlands	Conference abstract (empirical research)	Transplant outcomes comparisons	All cases of OD after euthanasia in The Netherlands until 2015	Retrospective	Database search
Bollen, et al.,27 2017	English	The Netherlands	Letter to the editor	To discuss some ethical issues that should be considered when discussing OD following euthanasia	Ethical aspects	Discussion paper	Database search
Bollen, et al.,28 2017	English	Belgium	Research letter	To examine the number of patients undergoing euthanasia in Belgium who could potentially donate at least 1 organ	Exploratory discussion	Discussion paper	Database search
Bollen, et al.,25 2019	English	Belgium and The Netherlands	Exploratory discussion	To discuss whether OD after euthanasia should be possible in children and adolescents, and what are the legal, medical, and ethical conditions for the combined procedure	OD following MAiD among children and adolescents	Discussion paper	Database search
Bollen, et al.,74 2019	English	The Netherlands	Ethical and legal discussion	To explore whether it would be legally, medically, and ethically possible to perform ODE	Ethical and legal discussion	Discussion paper	Database search
Bollen, et al.,75 2020	English	The Netherlands	Conference abstract (empirical research)	To examine the results of kidney transplants that were donated after euthanasia	Donation/transplant outcomes	Observational, retrospective	Database search
Bollen, et al.,8 2021	English	The Netherlands	Response letter	Reply to the recent article by Buturovic,30 to be able to correct some statements and allegations	Exploratory discussion	Discussion paper	Database search
Bryan,29 2019	English	Canada	Conference abstract	To discuss a community hospital experience with OD after MAiD in Ontario	Abstract	Discussion paper	Database search
Buturovic,30 2021	English	Serbia	Exploratory discussion	To discuss the safeguard procedures in the OD following MAiD	Ethical and logistic discussion	Discussion paper	Database search
Buturovic,76 2021	English	Serbia	Response letter	To discuss the implications that allowing euthanasia for psychiatric disorders could potentially have (including regarding to OD)	Ethical aspects	Discussion paper	Database search
Buturovic,31 2022	English	Serbia	Reply to author	Reply to Bollen’s8 reply to Buturovic76 article	Provide discussion why OD after euthanasia should not be performed	Discussion paper	Database search
Casey et al.,32 2020	English	Canada	Reflection of a case	To outline a case of a patient wishing to direct their OD after receiving MAiD	Directed OD	Reflection/study case	Database search
Ceulemans et al.,97 2020	English	Belgium	Conference abstract: report of empirical research	To review experience with lung transplant after DCD-V and compare the outcomes with donation after brain death and DCD-III	Transplant outcomes comparisons	Case reviews	Database search
Cohen-Almagor,33 2013	English	UK	Exploratory discussion	After a brief presentation of the Act on Euthanasia, concerns are raised about i) the changing role of physicians and imposition on nurses to perform euthanasia; ii) the physicians’ confusion and lack of understanding of the Act on Euthanasia; iii) inadequate consultation with independent experts; iv) lack of notification of euthanasia cases, and v) organ transplantations of euthanized patients. Finally, some suggestions designed to improve the situation are offered.	Explore issues regarding the Act on Euthanasia (Belgium)	Discussion paper	Database search
Comité d’éthique de Transplant Québec,77 2018	French	Canada	Unpublished report of ethics committee at Transplant Québec	To provide ethical information about OD after MAiD to practitioners who may receive this request	Ethical considerations of OD after MAiD	Report	Database search
Commission de l’éthique en science et en technologie,34 2016	French	Canada	Unpublished report of Québec Science and Technology Ethics Committee	To formulate recommendations for OD following MAiD from an ethical perspective	Contains review of legal context, including refusing or stopping life support in competent and non-comptetent patients, and the conditions required for organ retrieval; ethical values and how these apply to donors, family, health care professionals, society, and institutions; and ends with 5 recommendations	Report	Database search
Cook,79 2018	English	Canada	News article	To discuss the possibility of amending the law to allow ODE	Exploratory discussion	Discussion paper	Database search
Cook,80 2020	English	USA	News article	To discuss the position of the New England Journal of Medicine after a recent issue published in the journal	Exploratory discussion	Discussion paper	Database search
Cook,78 2014	English	The Netherlands	News article	To discuss ethical issues related to linking euthanasia and OD	Ethical aspects	Discussion paper	Database search
Cronin,81 2014	English	UK	Reflection/response letter	To present a reflection around death by donation on individual authorization, assisted suicide, and OD in Switzerland	Explore potential issues in OD after euthanasia in Switzerland (response to the article from David Shaw62 who said OD after euthanasia should be considered due the low rates of OD)	Discussion paper	Database search
Deachman,82 2020	English	Canada	News article	To discuss the growing boon to OD associated with MAiD in Ontario	Exploratory discussion	Discussion news	Database search
Detry et al. 35 2020	French	Belgium	Review	To review the evolution of criteria for OD with special emphasis on DCD and OD with MAiD	DCD criteria including discussion of MAiD	Review/dicussion paper	Database search
Dobec,83 2021	English	Canada	News article	Interview with Dr. Jennifer Hancock about MAiD and organ and tissue donation and transplantation	To discuss aspects regarding organ donation following euthanasia	Discussion news	Database search
Downar et al.,49 2019	English	Canada	Guidance for policy	To analyze organ and tissue donation in the conscious, competent patient from legal, medical, and ethical perspectives; develop and disseminate guidance for policies and clinical procedures for offering organ and tissue donation to patients who have made a decision that will lead to imminent death; develop a knowledge translation strategy that includes all relevant stakeholders; and identify questions for research	Political aspects (not only MAiD, but also withdrawal of life-sustaining measures)	Expert consensus to define the scope and key considerations regarding guidance to practice	Database search
Evrard et al.,45 2014	English	Belgium	New classification	To propose a new classification of Maastricht for DCD	New classification	Discussion paper	Database search
Glinka et al.,46 2021	English	Canada	Abstract + retrospective study	Study the results using DCD-MAiD liver grafts for transplantation	Liver transplantation outcomes	Retrospective study	Database search
Grant,86 2019	English	Canada	News article	Report of case and guideline	Highlight the guidelines	Discussion paper	Database search
Gruben & Chandler,47 2017	English	Canada	Journal article	To explore the legal and ethical questions that arise regarding OD following MAiD in Canada	A review of federal and provincial laws and policies governing MAiD and OD, in addition to the relevant national and international literature	Discussion paper	Database search
Haensel and Kompanje,84 2021	Dutch	The Netherlands	Paper	To discuss organ donation following MAiD from an ethical lens	Exploratory discussion	Discussion paper	Database search
Healey et al.,48 2021	English	Canada	Protocol	To describe a protocol for lung donation following MAiD at home and demonstrate excellent postoperative outcomes	Protocol for lung donation after MAiD at home	Discussion paper	Database search
Kinnaert,50 2011	French	Belgium	Review	Review of DCD and ethical issues of practice including OD after euthanasia	DCD and ethics	Review	Database search
Kirby,51 2016	English	Canada	Ethical exploratory discussion	To discuss if controlled donation after assisted death is more or less ethically problematic than standard controlled organ donation after circulatory determination of death	Ethical aspects	Reflection	Database search
Kirkey,88 2017	English	Canada	News article	To discuss the pressure that OD can cause MAiD patients	Ethical aspects	Discussion paper	Database search
Kirkey,52 2019	English	Canada	News article	To discuss why some experts argue that organs should be removed before death	Exploratory discussion	Discussion paper	Database search
KNMG,42 2017	Dutch	The Netherlands	Report of symposium	Report of oral presentations and workshops of a symposium	Subject of the symposium was “around dying”	Discussion paper	Database search
Kompanje,38 2019	Dutch	The Netherlands	Journal article	This article is a reaction to the article “Organ donation after euthanasia: legal considerations and issues”, which was published in the same journal	Discusses using an arterial line in a patient who is about to donate organs following euthanasia, and is followed by a reaction from the author of the original article (Bollen)	Discussion paper	Database search
Lemaitre & Hubert,53 2017	French	Belgium	Case report with legal/ethical review	To review case of ALS patient who was an organ donor after MAiD, with review of legal framework and ethical principles	Legal and ethical principles that must be in place for proper implementation of OD after MAiD; contains a description of process for MAiD and a few details about criteria for OD (generally only those with neuro diseases or mental illness)	Case report with review	Database search
Linkins,54 2019	English	Canada	Podcast audio reading	Reflection of the experience of having a best friend going through MAiD	Reflection	Discussion paper	Database search
Lossignol,89 2017	French	Belgium	Editorial	Editorial discussing the publication of Lemaitre and Hubert53 about ALS OD in the same issue of the journal	Examination of MAiD procedure and estimates of potential donors by MAiD	Discussion paper	Database search
Luke et al.,98 2022	English	Canada	Retrospective study	First Canadian report evaluating recipient outcomes from kidney transplantation following MAiD	Kidney transplantation outcomes	Retrospective study	Database search
Middleton,55 2019	English	Canada	Response letter	To provide comments on OD after MAiD based on the publication of guidance for policy on donation after MAiD and other competent donors	Commentary	Discussion paper	Database search
Middleton,90 2020	English	Canada	Letter to the editor	To discuss why the transplant community has little to gain and much to lose if it endorses directed donation after MAiD	Directed OD	Discussion paper	Database search
Milne et al.,91 2017	English	Canada	News article	To discuss the ethical issues in combining OD and MAiD	Ethical aspects	Discussion paper	Database search
Mulder et al.,39 2017	Dutch	The Netherlands	Article	Introduction of the guideline on OD after euthanasia to the medical professionals	Procedural aspects of the OD following MAiD	Description of guideline	Database search
Mulder,57 2019	English	The Netherlands	Reflective paper	Reflection on the Canadian guidance and the creation of the Dutch clinical guideline currently in use in The Netherlands	Commentary	Discussion paper	Database search
Mulder et al.,85 2020	Dutch	The Netherlands	Article	Response to an article by Haensel and Kompanje84	The update of the Organ Donation Law does not imply that a physician is obliged to request a patient who is about to undergo euthanasia donate their organs	Discussion paper	Database search
Mulder & Sonneveld,10 2017	English	The Netherlands	Letter to the editor	Report of the first case of OD following MAiD at home	Describe the case	Description of procedure	Database search
Mulder & Sonneveld,56 2018	English	The Netherlands	Exploratory discussion	To describe procedures developed in The Netherlands to provide MAiD at home followed by OD	MAiD procedures at home	Description of procedure	Database search
Nederlandse Transplantatie Stichting,41 2017	Dutch	The Netherlands	Manual	Description of concepts, process, and procedures	Manual to guide practice	Manual	Database search
Nederlandse Transplantatie Stichting,40 2021	Dutch	The Netherlands	Manual	Description of concepts, process, and procedures	Manual to guide practice	Manual	Database search
Pauls,87 2018	English	Canada	News article	To discuss the impact of OD on end-of-life experiences of those undergoing MAiD	Exploratory discussion	Discussion paper	Database search
Philpot,58 2018	English	Australia	Exploratory discussion	To explore the practical and ethical considerations that need to be reviewed in order to support OD after assisted dying	Practical and ethical discussion	Discussion paper	Database search
Rawstorne,92 2016	English	UK	News article	To bring to public attention to some ethical issues that can arise from OD after MAiD	Ethical aspects	Discussion paper	Database search
Regionale Toetsingscommissies Euthanasie, 2017	Dutch	The Netherlands	Annual report	Overview of all euthanasia cases in 2017 in The Netherlands	Euthanasia cases	Annual report	Database search
Rosenbaum,59 2020	English	USA	Editorial	To discuss a case study of a man with ALS who wanted to donate all of his organs before he died and some of the ethical concerns surrounding combining OD and MAiD	Ethical aspects	Discussion paper	Database search
Saad,1 2017	English	USA	Essay/discussion	To describe and evaluate the Belgian euthanasia experience by considering practice and policy, both before and after the formal decriminalization of euthanasia in 2002	Legislation and ethical aspects	Discussion paper	Database search
Sami et al.,60 2020	English	Canada	Conference abstract: report of empirical research	To report on the unique experience of the team in OD following MAiD and the first reported outcomes from the procedure in North America	Transplant outcomes	Retrospective analysis of case reports	Database search
Shapiro,61 2018	English	Canada	Editorial	To explore the possibility of OD as a mode of euthanasia (MAiD) and to clarify the process of OD and the dead donor rule	Ethical aspects	Discussion paper	Database search
Shaw,62 2014	English	UK	Editorial	To discuss the possibility of OD after assisted dying in Switzerland	Ethical aspects (and practical issues)	Discussion paper	Database search
Smith,93 2021	English	Canada	News article	To discuss the ODE	Exploratory discussion	Discussion paper	Database search
Société Belge de Transplantation,63 2015	French	Belgium	Brochure, which appears to be for general public	To increase knowledge of the process, improve quality of life of people with terminal illness, and save lives	Description of processes, kidney transplant tool, and resource (contains many contact numbers for more info)	Discussion paper	Database search
Somerville,64 2019	English	USA	Editorial/essay	To discuss ethical issues related to linking euthanasia and OD	Ethical aspects	Discussion paper	Database search
Tajaâte et al.,94 2021	English	The Netherlands	Case report with legal/ethical review	To describe the procedure of OD after euthanasia starting at home following anesthesia in a former health care professional suffering from multiple system atrophy	Exploratory discussion	Case report	Database search
Trillium Gift of Life Network, n.d.,65	English	Canada	Document of organization/institution	To provide the annual report for 2017/2018 of the activities and plan from Trillium Gift of Life Network	Processes	Discussion paper	Database search
University Health Network Foundation,95 2021	English	Canada	News article	To discuss the first case of transplant after MAiD at home performed at University Health Network (mainly based on the article5 that has been published)	Lung donation	Discussion paper	Database search
van de Vathorst & de Beaufort,96 2016	English	USA	Editorial	To discuss the ethical and moral issues related to OD following euthanasia	Ethical aspects	Discussion paper	Database search
van Dijk et al.,43 2013	Dutch	The Netherlands	Case report	First case report of ODE in The Netherlands	Procedural aspects of the OD following MAiD	Case analysis	Database search
van Dijk et al.,67 2018	English	The Netherlands	Case report	To describe a case from the Erasmus Medical Centre in November 2015; provide some suggestions to ensure that the request for euthanasia is separated as much as possible from the wish to donate organs; discuss ways to inform possible candidates of the existence of ODE	Case report analysis for improvement of process	Case report	Database search
Van Raemdonck et al.,68 2011	English	Germany	Report of empirical research	To report on experience with lung transplantation after euthanasia, to present recipient outcomes, and to discuss practical and ethical considerations	Transplant outcomes	Case reviews using a prospectively gathered database	Database search
Van Raemdonck et al.,100 2013	English	Belgium	Conference abstract: report of empirical research	To examine outcomes in recipients transplanted with lungs recovered from controlled DCD-V (euthanasia donors)	Transplant outcomes	Retrospective review of cases	Database search
Van Raemdonck et al.,69 2016	English	Belgium	Conference abstract: report of empirical research	To examine early and long-term survival of lung transplantation following euthanasia	Transplant outcomes	Retrospective review of cases	Database search
Van Raemdonck et al.,101 2018	English	Belgium	Conference abstract: report of empirical research	To compare survival between lung transplant recipients who received an allograft from a DCD donor or donation after brain death donor	Transplant outcomes	Retrospective review of cases	Database search
van Reeven et al.,70 2020	English	USA	Report of empirical research	To assess the outcomes of liver transplants with grafts donated after euthanasia (DCD-V) and to compare them with results of the more commonly performed LTs with grafts from donors after circulatory arrest resulting from withdrawal of life support (DCD-III)	Transplant outcome comparisons	Retrospective cohort study	Database search
van Smaalen et al.,44 2018	Dutch	The Netherlands	Article	To provide an overview of the practice of ODE for general practitioners	Introducing ODE to general practitioners and discussing what they need to do in an ODE procedure	Discussion paper	Database search
van Suylen et al.,66 2021	English	The Netherlands	Prospective study	To underline the potential of DCD-V heart donation for both clinical heart transplantation and research on human donor hearts	Heart donation (possibilities)	Prospective study	Database search
van Wijngaarden et al.,99 2016	English	USA	Case report	To discuss the ethical and legal concerns regarding ODE	Ethical aspects	Case reports	Database search
Yazdani et al.,71 2018	English	Canada	Discussion paper	To discuss the ethical-legal issues raised by MAiD and OD by analyzing issues raised in 4 possible scenarios for OD to occur in the context of MAiD	Ethical aspects	Case analysis	Databases search
Ysebaert et al.,72 2015	English	Belgium	Conference abstract: case reports	To report on OD following euthanasia in Belgium	Donation/transplantation outcomes	Case reports	Databases search

ALS, amyotrophic lateral sclerosis; BC, British Colombia; DCD, donation after circulatory death; MAiD, medical assistance in dying; N/A, not applicable; OD, organ donation; ODE, organ donation euthanasia; QI, quality improvement

Appendix III: Detailed description of codes and categories from qualitative analysis (part I)

Categories	Codes	Files	# of references
Definitions, legislation, and practice	Guidelines or guidance	10	25
	Legal rules or regulations for OD MAiD	49	141
	Maastricht category	8	10
	MAiD vs suicide	3	3
	Institutional requirements	8	15
Ethics, dilemmas, and consensus	Children’s OD and/or euthanasia	5	11
	Dead donor rule	29	51
	Directed OD	14	29
	Disclosure of recipients’ info for MAiD patients	3	3
	OD conversation	47	108
	Organ donation euthanasia: death by donation	25	64
	Cost saving	2	2
	Respect for patients’ wishes and autonomy	40	64
	Ethical dilemmas	14	22
	Ethical safeguards for OD following MAiD	22	91
	Recipient objection	15	16
Consent and objection	Confidentiality of MAiD decision/OD	5	10
	Consent to MAiD	34	52
	Consent to OD	36	42
	Deterioration of patient	4	4
MAiD and the public	Family’s perception	13	15
	Patient’s perspective	3	6
	Public awareness	5	5
	Public perception	18	28
	Societal pressure	38	58

MAiD, medical assistance in dying; OD, organ donation.

Appendix IV: Current legislation for medical assistance in dying and organ donation

Country	Main legislation	Criteria for MAiD	General rules for organ donation consent
Belgium	Belgian Euthanasia Act (2002)*	Competent individuals Attained majority age or is an emancipated minor The request is voluntary They are in “a medically futile condition of constant and unbearable physical or mental suffering that cannot be alleviated”(p.1)	Presumed consent (opt out) system: the patient is considered in favor of donating their organs unless they express their desire otherwise.4
Canada	Bill C-14103 (2016) and later modified by Bill C-7† (2021)	Competent individuals 18 years or older The request is voluntary They have a “grievous and irremediable medical condition”(p.1) Give informed consent	Explicit consent regime: the patients directly indicate their choice of organ donation (eg, in the health card; opt-in). The exception is Nova Scotia, as it has a presumed consent system (opt-out). The patient is considered in favor of donating their organs unless they express their desire otherwise.5
The Netherlands	Dutch Euthanasia Act (Dutch Termination of Life on Request and Assisted Suicide Act) 2002105	Competent individuals 12 years or older The request is voluntary They are experiencing “unbearable suffering with no prospect of improvement”(p.1)	Active donor registration system: the patient (if not registered by own choice) is notified and asked about their desire for organ donation. If no response is obtained, the patient is registered as “no objection to organ donation,” which means that consent is assumed.4,26,41

^*–The Belgian Act on Euthanasia of May 28th 2002. Eur J Health Law 2003;10:329–35.

^† –Parliament of Canada. Bill C-7: An Act to amend the Criminal Code (medical assistance in dying), C-7, forty-third parliament, second session (2021) [internet]. Parliament of Canada; 2021 [cited 2021 May 4]. Available from: https://parl.ca/DocumentViewer/en/43-2/bill/C-7/royal-assent.