The Mitzvah of Organ Donation

by Rabbi Joseph H. Prouser

From The United Synagogue Review, Spring 1997

The inestimable value of human life is a cardinal principle of Jewish law. This principle includes an obligation for maintenance of our own health and for self-preservation. This obligation, known as pikuah nefesh, also includes the duty to save the life of one's fellow human being, should he or she be in mortal danger. This is the significance of the Commandment: "You shall not stand idly by the blood of your neighbor" (Lev. 19:16). Codifying this mitzvah in his Mishneh Torah, Maimonides emphasizes how broadly its obligation devolves: "Anyone who is able to save a life, but fails to do so, violates 'You shall not stand idly by the blood of your neighbor.'"

These sources provide the halakhic basis for the decision by the Rabbinical Assembly's Committee on Jewish Law and Standards that "the preservation of human life is obligatory, not optional. When needed for life-saving transplantation, withholding consent for post-mortem tissue donation must be considered forbidden." This decision is the conclusion of my responsum, "The Obligation to Preserve Life and the Question of Post-Mortem Organ Donation," which the Committee recently adopted. Based on this responsum, the Committee has also unanimously approved a Conservative Movement Organ Donor Card, published and distributed in a joint effort with The United Synagogue of Conservative Judaism.

The actions of the Conservative Movement to urge its members to register as organ donors reflect the compelling urgency and the massive need for organ transplants. Well over 40,000 people are on the waiting list of the United Network for Organ Sharing. Every thirty minutes, a name is added to this national waiting list. Due directly to the shortage of willing donors, thousands of adults and children die each year. The cost in human lives is staggering: According to one estimate, as many as nine people die each day for lack of available organs.

The life-saving impact of organ donation reaches far beyond the sizable number of potential recipients. Prospective living donors, as well as recipients, are needlessly placed at mortal risk by the shortage of cadaver organs. Desperate parents want to donate organs even when doctors are unwilling to do the operation because they think it would be futile, or would entail too great a risk to the donor. Dr. Thomas Starzl, the renowned surgeon who pioneered liver transplants, now refuses to perform transplants from living donors for this very reason. Nevertheless, medical reliance on living donors continues to mount. Such a trend in the field of transplantation places tremendous pressure on relatives of prospective organ recipients to imperil themselves by serving as donors. In 1994 alone, 2,980 kidney transplants were performed using living donors.

A specific aspect of this trend is particularly troubling. Spouses are increasingly being viewed as important sources for living organ donation. In cases where these spouses are also parents, as is common, spousal organ donation means that both parents (donor and recipient) -- and, therefore, their children's well-being -- are placed at mortal risk.

Even a minute risk to the living is a significant religious and halakhic datum. Former British Chief Rabbi Immanuel Jakobovits thus rules that donation of organs by living donors (even blood donation), while commendable, may not be viewed as obligatory because it may entail a measure of risk for the donor. Risk to life, that is, constitutes a mitigating factor which renders living donation "an act of supreme charity" -- but entirely optional. This risk is, by definition, completely absent in post-mortem donation. With the absence of risk as a mitigating factor, post-mortem organ donation is, logically, rendered obligatory.

To be sure, post-mortem donation of human tissue is not without difficulties from the perspective of Jewish law. Objections to this practice include the prohibitions against nivul ha-met (disgracing the dead body, as by disfigurement), hana'ah min ha-met (deriving benefit from a dead body), and halanat ha-met (delaying burial). In discussing these issues (collectively termed kevod ha-met), the Committee on Jewish Law and Standards concluded that just as the religious mandate to preserve life takes precedence over all other religious obligations, it also must be given precedence over kevod ha-met. It thus affirmed the statement of Rabbi Isaac Klein in his Guide to Jewish Religious Practice that "there is no greater kevod ha-met than to bring healing to the living."

Based on the precedence of pikuah nefesh, the seriously ill are required to eat on Yom Kippur and it is forbidden to circumcise a sick or weakened infant if this would further compromise his health. The circumcision must be delayed, for, as the Shulhan Arukh observes, "preservation of life overrides all other considerations." (The prohibitions against murder, sexual immorality, and idolatry are, under normal circumstances, the only exceptions.) In other words, it is not merely permissible to delay what would be a life-threatening brit milah. Indeed, it would be sinful to perform the circumcision under such circumstances.

Similarly, it would be sinful to impair one's health by fasting while seriously ill, or to wait until the conclusion of Shabbat or Festivals to drive a sick or injured party to the hospital. Indeed, according to the Shulhan Arukh, "One who is zealous (and eagerly violates the Sabbath in such a case) is praiseworthy." The recent decision on post-mortem organ donation reflects this same Jewish core principle. It is sinful to observe kevod ha-met at the expense of other human beings' lives. Thus, it is contrary to Jewish law -- and Jewish morality -- to withhold consent for post-mortem donation of organs needed for life-saving transplantation.

Sadly, many members of the Jewish community have been reluctant to register as organ donors. Donor rates are markedly low in areas with predominantly Jewish populations. This is due in part to the misperception that Jewish law forbids organ donation. Perhaps the most decisive factor in this reluctance, however, has simply been the widespread aversion to any interference with the dead among most Jews. In general, this aversion reflects entirely appropriate devotion to venerable religious principle, and should be commended.

Kevod ha-met, the dignity and honor of the dead, is a weighty and cherished religious imperative. This is indicated by the designation given those charged with the religious task of attending the dead and preparing them for burial: Hevra Kadisha, the "Holy Society." Judaism teaches the sanctity of the human body as a reflection of the "Image of God" which is in every human being. This sanctity adheres to the body even after mortal life has ended.

It is precisely a sensitivity to such well-intentioned sentiments which characterizes the educational campaign undertaken jointly by the United Synagogue of Conservative Judaism and the Rabbinical Assembly to register Conservative Jews as organ donors. In so doing, we reflect the similar sensitivity of the late Israeli Chief Rabbi, Isser Y. Unterman who, at the very onset of the transplant era 45 years ago, called upon rabbis "to influence relatives and to persuade them to consent" to organ and tissue donation. Framing this teaching in terms of persuasion rather tha n coercion does not imply that this life-saving action is elective. Rabbis and Jewish communal leaders frequently engage in educational endeavors and persuasive techniques aimed at generating compliance with clear religious obligations. Persuading a Jew to comply with the laws of Shabbat or kashrut, or to engage in Jewish study, does not suggest that such observances are optional -- just as The United Synagogue's campaign Jewish Living Now is a wise and welcome recognition of Jewish religious obligations.

Consenting to post-mortem organ donation may be emotionally difficult; that difficulty may in part reflect appropriate religious sentiments. However, we are obligated to preserve life. We ought not, as our final act, glorify strictly subjective aversions, aesthetic objections, and personal preference at the expense of human life. As in many areas of human endeavor and religious expression, we serve God by appropriately identifying our priorities and acting accordingly. As Rabbi Jerome Epstein has taught us, a Conservative Jew "employs learned Jewish values to guide behavior even when it conflicts with personal feeling or inclination."

It is essential that one undertaking persuasive outreach in regard to the mitzvah of pikuah nefesh sensitively place organ donation into a constructive context in communicating with prospective donors or responsible next of kin. Referring to life-saving transplant procedures as the "harvesting" of organs, for example, evokes a sense of violence and disregard for the humanity of the deceased. "Recover" or "retrieve" are more appropriate terms to describe the donation process. It is similarly imperative that a ventilator not be referred to as "life-support," as this seems to imply that the patient is not yet dead. (The ventilator is used following death to maintain circulation of oxygenated blood to viable organs.)

Those contemplating organ donation should also be made aware that studies show that donation of one's organs helps to shorten the time needed by bereaved family members to recover from their loss. Serving as an organ donor thus not only saves lives but also provides comfort and healing to one's own loved ones. It does not remove the pain or loss, but organ donation allows something good and uplifting to be salvaged from an otherwise horrible occurrence. Families of donors know their loved one will never be forgotten by those whose lives they save and report a sense of extended family and community with other donors and recipients.

Given the increasing sophistication and success of transplant technology, and the increased confidence regarding determination of death, the post-mortem donation of vital organs clearly constitutes pikuah nefesh -- the saving of human lives. Indeed, one individual can save as many as eight or more lives by consenting to donation. Such an act of pikuah nefesh overrides all other pertinent religious obligations and considerations. The demand for organs far outweighs the supply, creating thousands of desperate, specific, life-threatening situations. Jewish law, therefore, requires us to grant our consent for post-mortem organ donation when requested by doctors or hospitals for use in life-saving transplant procedures.

This religious obligation can be fulfilled by personally registering as a donor by, for example, properly completing the Rabbinical Assembly/United Synagogue of Conservative Judaism donor card, and carrying it on one's person. The donor card additionally provides a form for use in informing family members of one's intention in this matter. It is most advisable to include written documentation of one's donor status as part of a more general "living will."

The preservation of human life is obligatory, not optional. Since all conflicting religious obligations are suspended, and specific, readily identifiable human lives are at stake, withholding consent for post-mortem organ donation when needed for life-saving transplant procedures is prohibited by Jewish law. This applies to the individual in anticipation of his or her own death, as well as to health care proxies or next of kin, whenever they are legally empowered to make such decisions on behalf of the deceased. The identity and, certainly, the religious status of the recipient are irrelevant. A bereaved family member who grants consent for organ donation acts as an agent and partner of the deceased in observance of the mitzvah of pikuah nefesh, in saving human lives. By so doing, he or she renders only profound and genuine honor to the deceased, while simultaneously bringing comfort to those who mourn. When needed for life-saving transplantation, withholding consent for post-mortem organ donation must be considered forbidden.