HHH Column: Bodies, selves, and slips of paper – reflections on the donor codicil
The HHH column is a monthly blog in which History, Health & Healing members share their thoughts on research, current affairs, or anything to do with medical history. Each edition is written by a different member — in due time, we hope to offer everybody a chance to publish a contribution. This month, the floor is for Florian van der Zee, a PhD candidate at Erasmus MC University Medical Centre. His research combines historical and philosophical perspectives to explore the development of voluntary and unpaid donation of bodily materials in Dutch medicine. In this column he reflects on the history of the donor codicil as a moral-historical object.
Bodies, selves, and slips of paper – reflections on the donor codicil
By Florian R. R. van der Zee
About two years ago at a birthday party, as I explained the PhD project I’d started working on some months prior (I’m fun at parties), the old and slightly battered trace of a decision taken years back emerged from a wallet: a codicil communicating the owner’s consent to postmortem organ donation. It was handed to me carefully – as over the years it must have been moved between successive wallets with increasing care, “just in case” – and after I was done inspecting it, it was tucked away safely again in its designated slot. The memorabilium fitted our conversation well: my PhD research has me pondering the historicity of morality through the rise of voluntary, unpaid donation of bodily materials in 20th-century Dutch medicine – together with Noortje Jacobs, who foreshadowed the overarching research project in an HHH column in March 2021, and depending on the sub questions with other colleagues, too. As the research progressed and my memory of meeting this significant little object coalesced with other unexpected encounters, my interest in the codicil as a moral-historical object grew. In this column, I will reflect on what the donor codicil has shown itself to be over the course of its life in Dutch medicine.
The codicil as a solution to a practical problem[1]
The codicil started out as a solution to a practical problem – but not the problem you might expect. The first codicils were issued in 1950 by the Dutch Red Cross’ Central Committee for the Cornea Centres. By the mid-1940s, demand for corneas for the novel treatment of cornea transplantation began to outstrip the supply of eyes removed from the living for medical reasons or taken from the unclaimed dead.[2] Spurred on by ophthalmologist E.C. Gravemeyer and in consultation with the Health Council, the Ministry of Social Affairs sought to increase the supply.[3] As postmortem eye removal legally required the deceased’s written consent or that of their relatives, and as removing this requirement was deemed politically unviable, they inquired whether the Dutch Red Cross was interested in organising a campaign to motivate people to part with their corneas after death.[4] The charitable organisation, the idea went, had experience with the required propaganda work.[5]
By this time, the Red Cross ran the Dutch Blood Transfusion Service, recruiting and organising volunteers willing to donate blood for free – in keeping with the Red Cross’ ideal of charity. Upon accepting the request, the Red Cross considered two ways of organising cornea donations. “Plan A” was to organise a codicil registry and actively connect donors to cornea requests (as the Transfusion Service did with blood); “Plan B” was to base donations on the consent of the deceased’s relatives and to organise propaganda campaigns to increase donation willingness. In the end, only Plan B was deemed viable.[6]
When the Central Committee for the Cornea Centres set its propaganda campaign in motion, it soon got calls from people who wanted to actively enlist as donors. To have a satisfactory answer, the Committee developed a donor codicil form.[7] Thus, a dual system emerged that would be in place until the late 1990s, based around family consent and donor codicils people carried on their persons. And while the former was a direct response to the problem of organising consent, the second emerged to satisfy people’s desire to actively join the Cornea Centre’s undertaking.
The codicil as a membership token
For the people ringing up the Central Committee for the Cornea Centres, the codicil thus functioned as a device conveying social identity.
The codicil would form an integral part of donor recruitment until the late 1990s, not just for corneas but for organs and other tissues generally. The codicil’s institutionalisation and dissemination may have propagated a sense of donor identity more generally. (Especially if, as I would hypothesise additionally, the slips of paper and plastic that we used to put in our wallets – before the wallet’s dethronement by the mobile phone – often had identity conferring characteristics.) Theories of identity suggest such identity propagation may have promoted the internalisation of the moral prescriptions and ideals behind the codicil, like those of voluntary and unpaid donation.[8]
The codicil as a normative technology
As a technology facilitating consent to postmortem donation, the codicil embodied the terms on which consent could be given or withheld. As its history illustrates, this had unforeseen effects. In 1984, in the midst of a debate around the proper way to diagnose brain death, Adrienne van Till – a legal expert on death and the end of life – deemed official guidelines too loose. She subsequently used the fact that the donor codicil had to be a handwritten statement of consent to urge people to demand a more stringent determination of brain death when formulating consent.[9]
Since the codicil’s replacement by a central registry in 1998, such personal stipulations are no longer possible. The handwritten statement of consent was replaced by the ticking of boxes: yes or no to postmortem donation of one or more of a specified set of organs and other tissues. This allows for more efficient donation procedures, but it may also create a mismatch between the facilitated conditions for donating and some people’s conditions for doing so.
Reflections after the codicil
The 1998 central registry did not entirely replace the codicil. Initially, people who registered as donors still received a donor card; this was discontinued in 2019. Like the 1998 shift to a central registry, this doesn’t simply mark a shift in neutral technologies for communicating consent. The 1998 shift restricted the conditions on which consent could be given; if my reflections are correct, the 2019 shift marks the abolishment of the codicil as a membership token. The latter event fits broader developments: since the adoption of an opt-out system in 2020, “membership” is the default status, prompting governmental aspirations towards more “neutral” donation education (as opposed to donor recruitment).[10] The opt-out system may diminish the codicil’s significance as a membership token; the emphasis on neutrality may caution against official communications framing donor identity as a desideratum.
Revisiting the pasts in which the codicil emerged and functioned draws attention to shifting contents and contexts of donor identity. Ironically, the codicil’s dismantlement in 1998 and 2019 has at once increased the degree to which the government fixes what it means to be a potential donor and decreased the degree to which this identity is promoted as worth aspiring to. In a pluralistic society faced with organ shortages, we may want to revisit both developments.
[1] This section is based on: Florian R.R. van der Zee and Noortje Jacobs, “Making Moral Twins: The Moral Reconstitution of the Human Body in Dutch Medicine, 1930-1960,” unpublished manuscript, February 26, 2025.
[2] “Minutes of the meeting of the Health Council committee on cornea transplantations on Tuesday December 21, 1948,” archive inventory 2.15.33, no. 561, Dutch National Archives, 2-3.
[3] The Minister of Social Affairs to the Chair of the Health Council, October 17, 1946, archive inventory 2.15.33, no. 561, Dutch National Archives.
[4] The Chair of the Health Council to the Minister of Social Affairs, December 19, 1946, archive inventory 2.15.33, no. 561, Dutch National Archives.
[5] “Minutes of the Health Council committee on cornea transplantations Tuesday December 21, 1948,” 5-6.
[6] Report of the Committee on Cornea Transplantations Established by the Dutch Red Cross Daily Management on April 1, 1940 (Dutch Red Cross, 1949), archive inventory 175, no. 426, Dordrecht Regional Archives, 2.
[7] Central Committee for the Cornea Centers of the Dutch Red Cross Annual Report 1950 (Dutch Red Cross, 1950), archive inventory 175, no. 426, Dordrecht Regional Archives, 7-8.
[8] E.g., Judith Butler, The Psychic Life of Power: Theories in Subjection (Stanford: Stanford University Press, 1997), chap. 3.
[9] H.A.H. van Till-d’Aulnis de Bourouill, Doodgaan, wat is dat? Hartdood, klinisch dood, schijndood, hersendood (Utrecht: Bohn, Scheltema & Holkema, 1984), 35-37, 59.
[10] Prompting criticism of some of the decision’s consequences, e.g.: “Oproep aan VWS: heroverweeg besluit stopzetten donorvoorlichting door ervaringsdeskundigen,” Nierstichting, May 31, 2022, https://tools.nierstichting.nl/nieuws/2022/05/oproep-aan-vws-heroverweeg-besluit-stopzetten-donorvoorlichting-door-ervaringsdeskundigen/.