Introduction

Before we discuss the subject of organ donation in Judaism, it is important to understand the essence of the meaning of “organ transplantation.” Our body resembles a perfect machine that works as a result of the combination of organs, tissues, and cells. Under normal conditions, this machine works in harmony. However, for a number of reasons, an organ can sometimes lose its function and may then require external support. This support is first provided by drugs and sometimes by machines. Often, this can lead to a moment when the body fails to maintain its vital function without that vital organ. This is when organ transplant is of vital importance.

For organ transplant in humans, the appropriate donor is another human. However, under what circumstances can a donor donate their organs in this vital process? We will scrutinize the answer to this question from different aspects and try to comprehend the significance of organ donation, especially with regard to Jewish religious law.

Every day, people die because an organ cannot be located. Even in those who have never cared about religion, a divine fervor emerges when they face death. Under what circumstances will a person donate an organ? Rabbi Tendler, one of the highest religious authorities of our time, is both a specialist religious leader and a professor of Talmud and Biology at Yeshiva University (New York City, NY, USA); his teaching could provide an answer to this question. Unless there is a risk to the donor, the teachings state that it is an obligation to donate organs. Alaha will not obligate a living person to be a donor if there is a risk involved (although it is praiseworthy to do so); similarly, if the donation itself leads to a life-threatening situation, then a living person will not be allowed to donate any organ. Therefore, there are some cases when organs can be received from a deceased donor, as long as the donor still maintains their “liveliness.”

What does a donor still maintaining their liveliness mean? Does this mean “brain death”? How does Judaism approach this concept? Before we explore the answers to these questions, we present how Rav (Rabbi) Moshe Feinstein, who was the father-in-law of Rabbi Tendler, viewed, in religious terms, brain death in medicine. He stated, “The only criterion for death is the complete stoppage of natural breathing.” The absence of signs of life (ie, failure to respond to movements and stimulations in a patient displaying the symptoms of clinical death, stoppage of independent breathing, etc) is conclusive evidence that death has occurred. Stoppage of natural breathing must last for a period after which resuscitation is no longer possible. If a “clinically dead” patient is connected to a breathing apparatus, the teachings do not permit the breathing apparatus to be switched off.

On the other hand, some authorities approach the concept of brain death from a different perspective. Rabbi Yitshak Breitowitz teaches the following in this respect. In the past, it was not particularly hard to define death in either legal or halachic terms. In general, all vital systems of the body (respiratory, nervous, and circulatory) would stop simultaneously, and it would not be possible to prolong the functioning of any of these systems without the other(s) functioning properly. However, today, it could be possible to keep some of the organ systems working even long after other organs have stopped. This is as a result of remarkable technological improvements in life support, especially with the development of respiratory, cardiac, and pulmonary support equipment. Because we no longer have situations involving the synchronous stoppage of all systems, it has become necessary to define, precisely and accurately, which physiological systems are an indicator of life and which are not (if any).

How Is Brain Death Defined by Religious Scholars and How Is It Identified?
As an alternative to the previous definition of “unrecoverable stoppage of circulation-breathing,” the term “brain death” was mentioned for the first time in a report by a special committee of the Harvard Medical School in 1968. The current definition of death is a compound definition. Death is considered when the following happens: irreversible stoppage of circulatory and respiratory functions or irreversible stoppage of all brain functions, including the brainstem. This definition allows a patient in a coma, who is unable to breathe on their own but whose heart continues to beat because of oxygen supplied by means of a ventilator, to be declared dead.

The human brain consists of 3 basic anatomic parts: (1) cerebrum, (2) cerebellum, and (3) brainstem, which is composed of the midbrain, pons, and medulla extending downward to form the spinal cord. The cerebrum controls the memory, consciousness, and higher mental functions. The cerebellum controls various muscle functions, and the brainstem controls breathing and various reflexes (eg, swallowing, gagging). Although the patient may be in a deep coma and not responding to most external stimuli, the patient may also be quite alive. Such patients have a cerebrum that does not work, in the worst case; however, because the brainstem is healthy, the patient can breathe naturally and the heart keeps on beating. In this case, removal of organs for donation would be a murder without a question. This is even more cruel when the patient is fully conscious but is unable to respond, that is, in a “locked-in” state.

A second point to note is the relationship among breathing, circulation, and the brain. Like any organ or cell, the heart needs oxygen to survive; if there is no oxygen, it will stop beating. Breathing is controlled by the vagus nerve, the nucleus of which is located in the medulla of the brainstem. Therefore, natural breathing activity cannot occur when the brainstem is not working or damaged. It is this critical time between the stoppage of natural breathing and stoppage of the heart that defines the parameters of the event called “brainstem death.”

When a patient is in a deep coma and is completely unresponsive to external stimuli and there is a lack of brainstem reflexes (such as swallowing, gagging, coughing, sighing, hiccups, and ear-related signs), an apnea test will reveal that natural breathing is not happening. After this, tests are performed that measure the brainstem’s response to various external stimuli. These tests should be repeated within the next 6 to 24 hours to decide conclusively that recovery/resuscitation is not possible. During this time, life support should be supplied.

Sometimes, an additional test that might be required (when judged that other clinical tests are not sufficient to reach a conclusion) is the radionuclide cerebral angio (nuclide or radioisotope scanning). A harmless radioactive dye is injected into the patient’s bloodstream through the intravenous tube, which is normally already inserted into the vein. The investigation to be performed on patients with brain death will show that the circulation has suddenly stopped under the brain and there is no flow of fluid.

Outlook on Contemporary Remarks
As mentioned, Rabbi Dr. Moshe Tendler has been a vigorous advocate of the acceptability of the criteria for brain death in halachic terms. As the head of the Rabbinical Council of America Biomedical Ethics Committee, Rabbi Tendler has pioneered, among other innovations, the preparation of a care proxy form that allowed the removal of vital organs for transplant from patients relying on a ventilator whose brain death has occurred.

In a decree dated Cheshvan 5747 (November 1986), Rabbi Mordechai Eliyau, the head of Israeli Chief Rabbinate Council and the Chief Rabbi at the time, approved the criterion of “brain death.” This authorized the Hadassah Hospital to carry out heart transplant operations. This was based on the principles in Talmud that Chief Rabbinate of Israel delivered the judgment on the fact that brain death is the irreversible confirmation of breathing.

The teachings of Rabbi Eliezer Melamed, an important authority on this subject, provides a better understanding on cases in which organ donation is permitted. However, first, it is important to present reasons for opposing views. “Man” was created in the image of God. Therefore, the body should be respected as necessary in both life and death. According to the teachings of Torah, it is forbidden to make use of the body of a dead person. One of the reasons for this ban is because of damage to the dead body. Also, it is clear that burial duty (funeral) will not be observed, as it should be, if there are any missing organs.

This rule is applicable under normal circumstances. However, what if there is a patient whose life is at risk due to organ failure and there is a chance to save that person? Torah teaches that some rules can be violated in the face of life threats. Both Rabbi Goren, one of Israel’s most important authorities, and Rabbi Soloveitchik, a respectable scholar, have declared that donation by the family in these situations is a favorable and life-saving behavior. Although the opinion of the family becomes crucially important in such cases, if the person has consented to donate their organs while still alive, then their decision should be respected. Organ donation must be intended to save a life. Many authorities are against the idea of organ donation for the sole purpose of research and experimental studies.

In his teachings, Rabbi Melamed underscored that donation of organs could only be possible after conclusive brain death has occurred, according to all religious authorities. This moment in time must be determined in the presence of both specialist physicians and an authorized cleric. Those who donate their organs to the Halachic Organ Donation Society (HODS), which is headquartered in Israel, get the following statement on the back of the donor card: “With the approval of an authorised Rabbi.”

Although there are still opposing views in Jewish law today, religious authorities permit organ donation “to save lives” as long as necessary criteria are met. Today, a great many religious authorities who were members of HODS have donated their organs, with the provision that the above-mentioned criteria have been met, and have also expressed their consent by adding the above-given statement on the donor card.