A Jewish Perspective
on Organ Transplantation
by Kathie Kroot
Dedicated to the memory
of Joseph
Kroot
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A Jewish Perspective by Kathie Kroot Dedicated to the memory
of Joseph
Kroot |
|
April 9, 1995, Alisa Flatow, a Brandeis University Junior from New Jersey, was riding a bus in the Gaza Strip when a van loaded with explosives was driven into the bus. Shrapnel from the bomb went through her skull and she never regained consciousness. Stephen Flatow, her father, flew to Israel to confirm that the brain-dead young woman was his daughter. Staff at Sororkin Hospital in Beersheva asked him if he would be willing to donate his daughter’s viable organs. After consulting with his wife and making a conference call to his rabbis, Alvin Marcus and Rabbi Moshe D. Tendler of Yeshiva University, Alisa’s parents decided to follow the positive mitzvah of Pikuach Nefesh, the "Saving a Life." Alisa’s organs changed the lives of six people on the transplant waiting list. "People have called it a brave decision, a righteous decision, a courageous decision. To us it was simply the right thing to do at the time," said Flatow. The Flatow family decision had an emotional impact on a grieving Israel. Prime Minister Yitzhak Rabin told American Jews in May 1995 that "Alisa Flatow’s heart beats in Jerusalem." Even more, the Flatow’s decision made public a painful issue — Jewish views about organ donation.
Many Jews believe that Jewish law prohibits organ donation; this is despite the fact that most Rabbis and other Jewish scholars support the practice of organ donation. In a study done in the Toronto Jewish Community, the most often cited reason for not signing an organ donation card was that the Jewish religion forbids such an act. Many respondents to this study believed that they had been taught that Jewish law prohibits organ donation. In Toronto, it appeared that the more Jewish education that the respondent had; the more likely he was to believe that Jewish law prohibits organ donation. One could conclude that the Jewish educational system is not advocating organ donation.
This may also be true in Lexington, Kentucky. Upon finding that my husband, Lou, and I chose to donate Joseph’s viable organs, we were asked, "What did the Rabbi say?" "I thought Jews couldn’t do that?" One person even said, "I’m glad you did, I always thought if Jews could receive organs, then they should donate them." Once they told us that Joseph had suffered "brain-stem death," organ donation was the obvious next step for Joseph. For us, like the Flatows, it was the right thing to do.
The principle of pikkuah nefesh, the obligation to save people’s lives, comes from Leviticus 18:5, "You’ll observe My decrees and My laws, which man shall carry out and which by he shall live." The sages interpreted from the "...and by which he shall live," the commandments were given for the sake of life not death. Therefore, if a performance of a commandment endangers life, the need to preserve life supercedes. The only exceptions are the three cardinal sins of idolatry, forbidden sexual activities, and murder. That is to say, that if you must violate the Shabbat in order to save your life, not only are you permitted to violate the Shabbat, you are commanded to do so. Further, Jews are commanded not only to do virtually anything necessary to save their own lives; they are bound by the positive obligation found in Leviticus 19:16 "...you shall not stand aside while your fellow’s blood is shed --- I am Hashem." This verse according to Rashi and Sifra is interpreted to mean if someone’s life is in danger, you must try and save him. Later, the Chosen Misphat adds, "Although one is not required to endanger his own life to save another, he should not be overly protective of his own safety." Its clear that Jews are required to help others in need.
So, what issues keep Jews feeling that Jewish law forbids organ donation? According to Rabbi Robert Dobrusin, Beth Israel Congregation in Ann Arbor, Michigan, "The first and most obvious objection regards laws relating to the treatment of a body after death." Indeed, Jewish law does prohibit desecration of the body and gaining benefit from the body and delaying the burial of the body. A second objection could stem from the question of "How could a dead person be obligated to follow the commandment "to save a life?" Again, in Jewish law, the dead are not obligated to obey the mitzvot. The most serious objection to organ donation maybe the question as to "when is a person dead?" according to Jewish law. Organs for transplant must be taken while respiration and circulation is ongoing through artificial support. The classic Jewish definition of death "is the absence of spontaneous respiration in patients with no other signs of life."
Rabbi Moses Tendler states, "Saving any human life is halachically mandated so that we transgress the laws of Shabbat to do so." If the mitzvah of "saving a life" is so paramount, that it supercedes other mitzvot, then here too, it must supercede the prohibitions concerning desecrating the body; gaining benefit from the body and delaying the burial of the body. According to KODA, (Kentucky Organ Donation Associates) donated organs are moved surgically in a routine operation similar to gall bladder or appendix removal. Normal funeral arrangements are possible. In fact, to keep a person who has been declared "brain dead" on life support without the intention of organ donation, might be considered halanat hamet, "the delay of burying a dead person," according to Rabbi David Novak.
The Committee on Jewish Law and Standards, The Rabbinical Assembly, "Chesed or Chiyuv," the obligation to preserve life and the question of post-mortem organ donation, December 1995, states "The consent required for organ donation is given prior to one’s death, or by surviving, responsible relatives....The act of consent while alive (or the consent of survivors) constitutes the fulfillment of the mitzvah itself." The article further states that it is curious, as to why organ donation has not been a long standing tradition in Judaism, since historically according to Maimonides, "All Israel are commanded to take life saving action." (Maimonides, Hilchot RotZeach u’Shmirat Nefesh, 1:14). Early Responsa written in the 1950, may have been influenced by rejection rate of early transplants leaving to question as to whether or not a transplant was really "saving a life." Today’s immuno-suppressive therapy already accounts for "a near doubling of the numbers of heart, kidney, and liver transplants performed. These advances have increased the survival rates. Kidney transplants currently enjoy an 80-90% success rate; heart transplant 80-90%; liver transplants 70-80%, lung 70-73%; and combined heart-lung transplant 70%. The Hartford Transplant Center’s Fact Sheet, Organ/Tissue Donation and Transplantation states that "Success implies restoration of the recipient’s quality of life and normal life expectancy."
Further early in transplant history, there was no sophisticated coordinated and computerized national and international organ registries, therefore the Rabbis may have felt that mandating donation would have been premature, as questions about "Who’s life is being saved?" Rabbis understood the pikkuah nefesh required to a "specific recipient" and early in transplant history recipients were more difficult to locate and identify. This is no longer the case as United Network for Organ Sharing (UNOS), a government sanctioned organ registry, maintains lists of 50,400 people currently awaiting transplants in the United States, alone. We know there is a need and who the individuals are in need. While about 18,000 transplants are performed each year, an estimated 8-10 people die every day waiting for a life-giving organ. We as Jews can certainly help.
When is a person considered dead? Rabbi Jakobovits, in 1975, summed up the basic issues stating "The question of defining the moment of death with precision has... been rendered both more difficult and more critically acute by... the demand for viable cadaver organs for transplant purposes. The lapse of only a few minutes may spell the difference between success and failure in such operations; on the other hand premature removal of organs from the dying may hasten death and constitute murder." All rabbinic authorities agree that the classic definition of death in Judaism is the absences of spontaneous respiration in a patient with no other signs of life. The question remains, is a person alive if the heart is beating, but his brain is dead, and so he can not breathe on his own? "Brain-death" has only been used to determine death since 22nd World Medical Assembly, in 1968. They defined "brain-death" as "permanent functional death of the centers of the brain that control breathing, pupillary, and other vital reflexes." Rabbis Seymour Siegel, Elliot Dorff, Avram Reisner, and David Golinkin, all of the Rabbinical Assembly, as well as Rabbi Moshe Tendler, an Orthodox authority on Jewish medical issues, and the Chief Rabbinate of Israel, are all proponents of this definition of death. Rabbi Tendler states that "We look for the cessation of all brain function, including the brain stem, the top, the cerebrum, the middle, and the base. If it’s all gone, the individual is dead." He further explained that newly developed MRI test can clearly differentiate between a patient in a coma and a patient who has expired.
The rabbis of the Mishnah, 0-200 C.E., wrote that if a person is buried underneath a heap of stones on Shabbat, one is allowed to remove the stones to rescue him. However, once he is found to be dead, one must wait until shabbat ends and then finish clearing of the rocks to bury him. The rabbis of the Gemara, 200-500 C.E., questioned when does the rescue effort stop. Opinion A, when you reach the nose and discover the victim is not breathing. Opinion B, When you reach the heart and discover it is not beating. Opinion A seems to would support that a "brain dead" person is dead, while Opinion B would seem to support that the "brain dead" person is alive, because the heart is still beating. The Gemara concludes that both opinions must hold that the breathing is essence of life as it is written in the Creation Story ..."All that is alive which is breathing." The conclusion of the rabbis was that if you dig and discover the heart first, and it is not beating, you should stop your digging, if the heart is not beating the person is not breathing and therefore dead. And if you discover the nose first, and find that there is no breathing, the person is dead. The rabbis support that a person is in fact dead as he can no longer breath on his own. The Talmud also discusses that a decapitation is the same as death even if movement continues. Today’s rabbis view "brain death" as a physiologic decapitation, even when machines support the viable organs.
In his talk, "The Ethics of Organ Donation," Rabbi Moses Tendler stated "...death ALWAYS meant brain death --- it was simply defined in cardiopulmonary activity before more sophisticated means of determination were available. The brain cannot be dead and body alive: "brain death" is an unfortunate misnomer." Medical studies have shown that if a person is truly "brain dead", even on life support, that person’s viable organs will cease to function in average of five days. The Rabbis are very clear that if the patient has suffered brain damage to the point that they are no longer able to function, but are able to breath on their own, without the aid of machine, they are NOT brain dead. This was the case for Karen Quinlan who after being removed from life support lived for multiple years. It was NOT the case for Alisa Flatow, in Israel. Nor was it the case for Joseph Kroot in Lexington, whose body began to deteriorate in the seven hours he was on "life support." While Joseph’s kidneys remained viable, his heart had deteriorated so that only his heart valves were used for two children who otherwise would have mechanical valves; and his liver had small areas of ischemia, lack of oxygen, which allowed only 70% of the liver’s hepatocytes to be transplanted into an individual who continued to wait for matching donor.
There are opposing opinions, mostly from right-wing orthodox groups, that consider "brain death" to be ambiguous according to a ruling by the late revered Rabbi Shlomo Zalman Auerbach.
These same groups opposed donation, and do not prohibit Jews from benefiting from organ transplants. Leaving other rabbis shaking their head from the ruling. Rabbi Tendler stating that "If a person is NOT dead by our halachic definition when he is "brain dead" then to go and take an organ from a nonJew means you are killing a nonJew to save a Jew." Rabbi Marc Angel states that this all-take and no-give policy is "morally repugnant."
Alisa Flatow’s case may have changed some minds in Israel on this issue. Weeks after her death, Rabbi Yehoshua Scheinberger, Health Minister of Eidah Haharedit, an body for Israel’s ultra-orthodox, made a ruling allowing the accepting of "brain death" and donating of organs with several conditions. These conditions include forbidding the donated organs to be transplanted into bodies of "non-believers, gentiles or Arabs who hate Israel." (Most secular Israeli fall in the category of non-believers.) A further condition is that an Orthodox rabbi sit on the committee that approves the transplant. These conditions were rejected by the Israel Transplant Association, and criticized by others who felt that there is no basis in Halakha or in Jewish morality to support limiting a donation to a Jewish or an observant Jewish recipient. Still, others like Rabbi Tendler feel that while the decision has an "halachical; emotional and sociological" error, it is a positive ruling for "brain death"
Still, many believe that biggest problem for donation is lack of communication. "If you ask the person the street," says Dr. Mordechai Kramer, an Orthodox Jew who coordinates the Lung Transplant Program at Hadassah Hospital, "the majority are willing to donate. It is their families who do not understand "brain death," they want to continue to believe that the patient will get better." The public has to reassured that donating an organ doesn’t mean that death will be hastened in any way. Further, families need to talk with one another to understand each other's wishes and beliefs. Rabbi Tendler states that "Torah does not require one to do something that is painful (e.g. emotionally painful to the family of the donor)," but wonders "how can saving a life be painful?" It can be painful, when there are questions that can’t be answered. Will my loved one feel that his body has been desecrated by organ donation or that his "gift of life" has brought honor to him? We knew Joseph’s wishes. We had talked as a family about this issue.
I have spoken with Rabbi Adland and Rabbi Slaton, and both support organ donation. The Reform and the Conservative Movements support organ donation. Further both movements has made donor cards available to members. Consult your Rabbi for any concerns. Sign and carry your religious affiliation card or the back of driver’s license. MOST IMPORTANT: Talk with your family and let them know your wishes, they are the ones who will make the decisions in the event you are unable.
We know that Joseph did not live a long life, but his life was full. He was kind, generous, a little impish, and Jewish. He could not read well, but his corneas are now reading. He didn’t find the cure to cancer, but he did follow the Jewish mitzvah of pikkuah nefesh and "saved lives." We are reminded of the ring given to Schindler in Schindler’s List, stating the Talmudic saying, "He, who saves a life, saves the world." What an honor for our Joseph.
More information about the Kroot family
