Good Intentions Aren’t Enough: Who Counts? Who Risks? Who Decides?

“Beneficence Sounds Like A Big Word”

Beneficence sounds like a big word, but the idea is quite simple: do good, and help people. In healthcare, it is the reason we treat patients, fund research, and try new things when the old ways are no longer enough.

The harder part about deciding what “doing good” actually looks like. Who gets helped first? What are we willing to risk to help someone? Who gets to decide what counts as benefit in the first place?

This month, each section takes a different approach on those questions. We start with organ donation and allocation, where there are never enough organs for everyone who needs one, and every system has to decide who gets the chance. Then we look at xenotransplantation, the idea of using animal organs, like pigs, for human patients. It could help many more people, but it raises questions of how much uncertainty we should accept, and whether Canadians are ready for it. The last section is meant to spark debate: kidney selling, and whether it could be justified on grounds of beneficence if legislation allowed some leniency,

Beneficence is rarely as straightforward as it sounds. Helping one person can cost another, and what looks like a good idea in a lab can look very different in real life.

We hope this issue leaves you with more questions than you started with, and good ones to talk about!

Organ Allocation Ethics and Fairness Disparities

There are never enough donated organs for everyone who needs one. So every transplant system has to answer a hard question: who gets it?

Most systems struggle with two goals that pull in entirely opposite directions. The first is to treat the sickest patient first, since they are closest to death. The second is to get the most benefit out of each organ, meaning it goes to the person most likely to live with it the longest. Choosing one can mean sacrificing the other. The Hastings Center describes this as a debate between urgency of needs and a “net transplant benefit, calculation” and every country and organ type strikes its own kind of balance (Caplan and Parent 2022).

Beneficence is the duty to do good and help patients. It’s the thinking behind the “maximum benefit” side of the debate. A donated organ is rare, so it should go where it will help the most (OPTN Ethics Committee 2015).

But “helping the most” depends on how we measure it. Transplant systems use scores to decide who is sickest and who will benefit most, and those scores only work if they see every patient clearly. The Markkula Center points out that the old liver scoring system underestimated how sick women were, so the math said women needed organs less than they did, and more of them died waiting (Kinney 2025). A similar point could be made about kidneys: how we score access to transplant shapes who look like a strong candidate in the first place (Yeung, Coates, and Li 2022).

So beneficence and justice depend on each other. Beneficence tells us to do the most good, but justice decides whose good gets counted. If some patients are undercounted,”maximum benefit” just repeats the same inequalities. This frames organ donation allocations as the clash between favouring the worst-off and maximizing total benefits, which is why neither one world unless the measuring stick is fair first (Bunnik 2023).

The Tradeoffs of Xenotransplantation

The waitlist for a human organ transplant has always been seen as an ever-running clock, with patients anticipating when they will be the next recipient. As such, physicians and researchers have begun to wonder whether the idea of xenotransplantation, or cross-species transplantation, could be a viable pursuit to shorten the waitlist. At the core of this endeavour is beneficence, one of the four main pillars of bioethics, which ensures physicians as well as researchers act in the patient’s well-being in the long term.

In this case, beneficence cannot be seen only as doing whatever it takes to help current patients; it has to account for future patients as well. With that in mind, a 2002 Canadian Medical Association Journal (CMAJ) article by Steven Wharry discusses how xenotransplantation must not be taken lightly. The risks of xenotransplantation were described as too unknown to carry on, and the report continued by recommending that Canada must halt clinical trials until there were proper regulations and boundaries created by Health Canada to assess the possibility of xenotransplantation as a viable option (Wharry 2002). Alternatively, the CMAJ elaborated that expanding into disease prevention and providing more potential human donors were the key to exploring the other substitutes rather than relying on xenotransplantation (Wharry 2002).

And yet, two decades later, researchers at the University of Saskatchewan found that gene editing with tools such as CRISPR-Cas9 has addressed two major barriers to xenotransplantation. The first is the potential rejection triggered by the pig-specific carbohydrate; the second is the risk of porcine retroviruses (Olson 2024). Two recipients, one with a pig-heart and another with a pig-kidney both survived; the pig-heart recipient survived within two months post-operation in 2022, and the pig-kidney recipient is still on the recovery track post-operation in 2024 (Olson 2024). These results demonstrate the advances in xenotransplantation, with work continuously improving and the outcomes looking promising, though they come from a very small number of patients.

But the two early recipients do not cancel out the ethical concerns of xenotransplantation. One side favours restricting transplantation to solely consenting humans. The other end of the argument highlights how the waitlist is far too long and a system with loose regulations, including private clinics offering alternative services to the public sector. Nevertheless, the overlap between both sides is that they state beneficence is at the core of their argument, and so, society must decide which argument aligns best with its current values.

The Monetary Valuation of Organs

In the context of Western society, attitudes towards the treatment of patients historically reflected a paternalistic perspective, in which doctors took an authoritative, ultimate role in deciding what was right for patients. As bioethical principles advanced with time, patients’ consent came to be taken into consideration for the benefit of their own persons; we define consent as a fundamental right, a boundary to protect the bounded individuals when it comes to medical intervention, and it is stressed on the physician-patient relationship. Yet, the principle of consent is overridden when it pertains to kidney selling. The problem is presented here:

Selling kidneys the moment commercial opportunities arose once a kidney could be removed with minimal risk. In the west, there were no laws against such transactions, but politicians and doctors were outraged, which resulted in enacted legislation to bar this problem; payment for kidney donation soon became illegal in most parts of the world (Richards 2009).

One justification in this legislation concerns the poor themselves making the decision to sell their kidneys, rather than the access of the rich to treatment and the exploitation of the poor as a source (Richards 2009). On this view, poverty is used as a basis for doubting voluntariness and thereby invalidating consent, which should be autonomously given. The grounds for this doubt are unrefusable offers and coercion by poverty (Richards 2009). The financial benefits of kidney selling affects the individual’s choice since monetary value is irresistible, thereby the element of voluntariness must be at least compromised, or abolished in extreme cases (Richards 2009). The idea is that, if you are an individual in need of support, it is not the case that you actually want to lose your kidney; rather, you want the instrumental value obtained at the end (Richards 2009).

Let’s consider that it follows that consent is not truly voluntary, that the individual does not want to lose their kidney under the pretense that they do not want to undergo surgery. It is the payment that incentivizes the patient—and, because payment is seductive, the concern is that the person making that decision may not fully understand the risks it entails. However, I find that it is perverse for anyone to claim on the basis of voluntariness, or to question competence, because the individual dislikes one element of the package. Moreover, it is also perverse to claim that someone in poverty would be incapable of understanding the risks of kidney selling because financial gain promises mobility. Outside of kidney selling, we make decisions within healthcare that may not always be favourable, but we constantly make these decisions anyway that best reflect our personal values and beliefs. For example, a woman going through early-stage breast cancer may not want a double mastectomy because of body image reasons yet chooses it anyway because she wants to reduce the risk of the cancer recurring in the future; she may also wish to avoid chemotherapy. Indeed, I argue for the leniency of kidney selling within healthcare systems under the principle of beneficence of the patient.

Different patients harbour different views about what constitutes a harm and a benefit according to their judgement, even if those views may not be morally acceptable to the physician (Beauchamp, 2019, Harms and Benefits in Health Care). If the person that wants to sell a kidney chooses to do so for financial mobility, with the additional benefit of the kidney going to a patient on dialysis, then it appears the benefits outweigh the personal risk for that individual. Simply disliking the idea of undergoing surgery does not establish otherwise. Furthermore, legally barring kidney selling does not necessarily stop people who desire mobility from selling their kidneys anyway; they may resort to dangerous methods, where risks may outweigh the benefits, especially when the procedure may directly harm their livelihood. This does not mean that every kidney sale would be beneficial or that the risks of exploitation should be dismissed. Within a regulated healthcare system, the person’s understanding of the risks, freedom from coercion, and access to appropriate medical care would need to be protected. The benefit to the recipient would not excuse neglecting the welfare of the person selling the kidney. If consent is meant to protect individuals’ authority over their own bodies, then poverty alone should not be grounds for denying that authority. Respect for autonomy and beneficence would require taking their judgement seriously while ensuring that the conditions of the transaction protect their welfare.

In Conclusion

The simple idea for this issue was that: beneficence means doing good and helping people. By the end, it got complicated fast.

In organ allocation, we saw that even a fair-minded system can quietly leave some people behind. Doing the most good only works if everyone’s needs are accounted for accurately. In xenotransplanation, we saw that a solution that could help far more patients also asks us to accept real risks and uncertainty. In kidney selling, it appears that regulated leniency seems justified, because it respects a person’s own judgment of what benefits them, provided there are safeguards for their understanding, their freedom from coercion, and their medical care.

The common thread here is that beneficence is never just about good intentions. It depends on who gets counted, who takes on the risk, and who gets a say in what “good” actually means.

So, we leave you with a few questions to ask. When resources are limited, who should come first? How much risk is worth it? And who gets to decide?

References

Beauchamp, Tom L. 2019.”The Principle of Beneficence in Applied Ethics.”In The Stanford Encyclopedia of Philosophy, Spring 2019 ed., edited by Edward N. Zalta. Stanford University.
https://plato.stanford.edu/archives/spr2019/entries/principle-beneficence/.

Bunnik, Eline M. 2023.”Ethics of Allocation of Donor Organs.” Current Opinion in Organ Transplantation 28 (3): 192–96. https://doi.org/10.1097/MOT.0000000000001058.

Caplan, Arthur, and Brendan Parent. 2022.”Organ Transplantation.” Hastings Center Bioethics Briefings. Last updated August 1, 2023.
https://www.thehastingscenter.org/briefingbook/organ-transplantation/.

Kinney, Elsa. 2025.”Inequities in Organ Transplant Allocation.” Markkula Center for Applied Ethics, Santa Clara University, April 16, 2025.
https://www.scu.edu/ethics/healthcare-ethics-blog/inequities-in-organ-transplant-allocation/.

Olson, Matt. 2024.”USask Researchers Exploring Pig Possibilities for Organ Transplantation.” WCVM Today, Western College of Veterinary Medicine, University of Saskatchewan, June 6, 2024.
https://wcvmtoday.usask.ca/articles/2024/06/usask-researchers-exploring-pig-possibilities-for-organ-transplantation.php.

OPTN Ethics Committee. 2015.”Ethical Principles in the Allocation of Human Organs.” Organ Procurement and Transplantation Network, Health Resources and Services Administration. https://optn.transplant.hrsa.gov/resources/ethics/ethical-principles-in-the-allocation-of-human-organs/.

Richards, Janet. 2009.”Consent with Inducements: The Case of Body Parts and Services.”In The Ethics of Consent: Theory and Practice, edited by Franklin G. Miller and Alan Wertheimer, 281–304. Oxford: Oxford University Press.
https://doi.org/10.1093/acprof:oso/9780195335149.003.0011.

Wharry, Steven. 2002.”Canadians Not Ready for Animal-to-Human Transplants.” CMAJ 166 (4): 493. https://www.cmaj.ca/content/166/4/493.

Yeung, Melissa Y., P. T. Coates, and P. K. T. Li. 2022.”Kidney Organ Allocation System: How to Be Fair.” Seminars in Nephrology 42 (4): 151274.
https://www.seminarsinnephrology.org/article/S0270-9295(22)00056-0/fulltext.

A Note, From Us

Thank you for reading this edition of our newsletter, Synapse. We’re grateful for your continued support and excitement as we grow our community.

1. Syn·apse: a junction between two nerve cells, consisting of a
minute gap across which impulses pass by dif usion of a
neurotransmitter.

In other words, where connection happens; Between neurons,
between ideas & subjects, and between people. Through BUSA,
we connect peers, philosophy, and science, in ways that spark
thought, dialogue, and discovery.

Until next month,
– BUSA

BUSA’s Newsletter Team

Ugoamaka Izuka – Editor-in-Chief Lauren Alberstat – Layout & Design
Jesse Alinas-Bacalzo – Research Coordinator
Alexander Ma – Research Coordinator