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Editorial

Religion, organ transplantation, and the denition of death


An intense debate has been rekindled in orthodox Jewish circles on whether brain-stem death is compatible with the denition 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 denition of death and only accept the traditional halachic denition of cardiorespiratory failure. This apparently regressive interpretation comes at a time when all countries are discussing the most eective ways of 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 clarication because of the strong reactions from many quarters after the release of that paper. In this statement, the RCA acknowledges that diering interpretations 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, conrmed 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 full three criteria. First, it must be based on sound scientic 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
www.thelancet.com Vol 377 January 22, 2011

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 denitions of death and the lack of a unied 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 organ transplantation. In Islam, there is also a debate about the concept and denition 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 sensitivities of dierent religions. Only a well-informed and knowledgeable workforce that understands and respects dierent beliefs and anxieties will be trusted at a time when dicult 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

For the paper by Michael Oliver and colleagues see Nephrol Dial Transplant 2010; published online October 20. DOI:10.1093/ndt/gfq628

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