From Framework to Practice: Implementing Ethical Safeguards for Donation after Assisted Dying in Aotearoa New Zealand

Introduction: Assisted Dying and Donation (ADD) presents complex ethical challenges at the intersection of end-of-life care and organ donation, including risks of coercion, conflicts of interest, and potential impacts on a person’s end-of-life experience. While ethical frameworks have been described, there is limited evidence on how these principles can be translated into safe and workable clinical practice.
Methods: We developed a national ethical framework for ADD alongside the development of clinical processes, with both evolving iteratively. This included translating ethical principles into referral pathways, consent processes and clinical protocols, while continuing to refine standard operating procedures, guidelines and resources for patients, whānau and healthcare providers. Development occurred in consultation with clinicians, ethicists, Māori (Indigenous people of Aotearoa New Zealand) advisors and people with lived experience, ensuring alignment with legal requirements, cultural safety and practical service delivery.
Results: Key ethical safeguards have been embedded into practice. These include separation of assisted dying and donation decision-making, separation of clinical teams, and structured reflection to support autonomous decision-making. First-person consent processes have been strengthened, and guidance developed for pre-mortem interventions to balance benefit and harm. Cultural safety has been incorporated through recognition of whānau (family group) involvement, tikanga-informed care (correct cultural procedures) and responsiveness to different worldviews. Early experience across a small number of cases demonstrates that ADD can be implemented in practice, while remaining relatively rare. Donors in this context provide explicit, first-person consent and are typically highly motivated; the opportunity to engage with them and their whānau over time allows greater confidence in the stability and understanding of their decisions. Implementation has also highlighted ongoing tensions, particularly balancing individual decision-making with whānau perspectives and ensuring equitable access.
Conclusion: ADD can be implemented in a way that is ethically robust and workable in practice when supported by clear safeguards and culturally grounded care. This remains an evolving process, requiring ongoing reflection, refinement and partnership. Translating ethical frameworks into clinical practice is critical to maintaining trust, protecting autonomy and supporting equitable access to donation. This approach may help inform other jurisdictions developing ADD pathways. These developments are also strengthening broader organ donation practice, particularly in relation to consent, cultural safety and engagement with whānau.