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Editorial

www.thelancet.com Vol 377 January 22, 2011 271

Religion, organ transplantation, and the definition of death

An intense debate has been rekindled in orthodox Jewish

circles on whether brain-stem death is compatible

with the definition of death by the Halachathe

collective body of Jewish law. Last week, the UKs Chief

Rabbi Jonathan Sacks caused widespread consternation

among physicians when he issued an edict stating that he

and his rabbinical courtthe London Beth Dinreject the

legal and medical definition of death and only accept the

traditional halachic definition of cardiorespiratory failure.

This apparently regressive interpretation comes at a time

when all countries are discussing the most effective waysof encouraging organ donation in an attempt to deal

with growing waiting lists for transplantation.

Sacks stance follows the release of a 110-page paper,

in June last year, by the Halacha Committee of the

Rabbinical Council of America (RCA), in which a previous

determination that brain-stem death constitutes halachic

deathalso the opinion of Israels Chief Rabbinatewas

overturned. On Jan 7, the RCA took the unusual step of

issuing a clarification because of the strong reactions

from many quarters after the release of that paper. In

this statement, the RCA acknowledges that differinginterpretations are held by halachic authorities and that

the membership is best served by allowing each Rabbi

to determine for himself...which halachic position he will

adopt. Further statements by other rabbis, many from

Israel and some from the USA, confirmed their support

for brain death as a valid criterion and added that to

adopt a restrictive position regarding donating organs

and a permissive position regarding receiving organs

is morally untenable. According to the Jerusalem Post,

Robert Berman, of the Halachic Organ Donation Society,

called for the document to be retracted and claims it

contains medical mistakes, citation errors, and historical

distortions. It certainly uses emotive languagefor

example, when it discusses the practice of ending

life support for patients with brain damage who are

intentionally removed from life support in order to cause

them cardiac arrest, thus putting them into the dead

donor category.

Any position and policy at the end of lifereligious,

ethical, or medicalshould fulfil three criteria. First, it must

be based on sound scientific evidence and understanding.

Second, it must have the best intention for both the

person whose life has ended and for the person who

needs an organ to prolong life. In other words, it must

do no harm. And third, it must be understandable and

supported by the individual within his or her cultural and

belief context.

Judaism is not the only religion in which uncertainty

over definitions of death and the lack of a unified

interpretation make people hesitate to become organ

donors. Michael Olivier and colleagues described in a

paper last October in Nephrol Dial Transplant how a recent

case of a Muslim patient on their renal transplant list

made them realise how doctors are often completely

ignorant about religious beliefs in the context of organtransplantation.

In Islam, there is also a debate about the concept and

definition of brain death, and it is forbidden to violate

the human body whether living or dead. However, as

in Judaism, altruism is also very important and saving a

life is regarded very highly in the Quran. The UK Muslim

Law Council ruled in 1996 that organ transplantation is

entirely compatible with Islamic beliefs. Yet, in Singapore,

which has a presumed consent system, Muslims are

automatically exempt from it, and Islamic countries

generally have a low rate of carriage of organ donor cards.In Tibetan Buddhism the belief is that, while preserving

physical integrity of the dead body is not seen as crucial,

spiritual consciousness may remain in the body for several

days after breathing has stopped and any interference

might disturb the persons next rebirth. Jehovahs

Witnesses have since the 1980s taken the stance that

organ donation and transplantation is an individual

choice under the assumption that no blood is transfused.

Sikhism and Hinduism are generally supportive of

transplantation because the physical integrity of the dead

body is not seen as an important concept.

With increasingly multicultural nations it is very

important that doctors discuss and are educated

about the meaning of death and the cultural sensitiv-

ities of different religions. Only a well-informed and

knowledgeable workforce that understands and

respects different beliefs and anxieties will be trusted

at a time when diffi cult conversations need to be

handled sensitively. Faith leaders and doctors need to

work together to avoid sowing distrust and confusion.

Religious doctrine needs to be interpreted with deep

understanding, humane wisdom, and humility.

The Lancet

Science

PhotoL

ibrary

For the paper by Michael Oliver

and colleagues see

Nephrol Dial Transplant 2010;

published online October 20.DOI:10.1093/ndt/gfq628