Two recent news items paradoxically raise the promise of more organ donations and the eventual end of them altogether. Facebook’s recent introduction of an organ donor status (link), an attempt to boost donor participation, affords a welcome opportunity to discuss a recent comprehensive work on Judaism and the definition of death. While many organs, particularly those most in demand, may be donated according to all contemporary rabbinic opinions, some critical organs–most notably the heart–can only be donated during the period after brain stem death and before irreversible cessation of heartbeat, about which rabbinic authorities debate whether death has yet occurred. My friend R. Dr. David Shabtai’s Defining the Moment: Understanding Brain Death in Halakhah (in the publication of which I played a small role) exhaustively reviews the halakhic literature to date, placing each view within the proper context and challenging each view’s textual, logical and medical bases. However, another recent news item points toward an upcoming resolution to this entire debate.
Brain death is never explicitly considered in the Talmud, leading recent halakhic decisors to arrive at five different positions on the subject:
- Acceptance of brain stem death – R. Dr. Moshe Tendler contends that brain stem death effectively severs the brain from the body, yielding the physiological equivalent of decapitation and hence death.
- Acceptance of whole brain death – R. Shlomo Zalman Auerbach accepts a dual definition of death–either the irreversible cessation of heartbeat or the death of the entire brain. Brain stem death inaugurates a condition of doubtful (safek) death, which is insufficient to allow organ harvesting.
- Doubtful acceptance of brain stem death – R. Hershel Schachter requires the continued functioning of the brain, heart and liver. R. Schachter considers the failure of only one system to be a case of doubtful death. He also accepts that cessation of blood flow to an organ is a case of doubtful death of that organ. Therefore, if brain stem death entails the cessation of blood flow to the brain, then the brain might be considered dead (doubt #1) and the person might also be considered dead (doubt #2).
- Partial acceptance of whole brain death – R. Ahron Soloveichik considered complete brain death to be part of a determination of death. He required the combined irreversible cessation of breathing, heartbeat and brain activity before death can be declared.
- Rejection of brain death – R. Moshe Feinstein, the Israeli Chief Rabbinate, R. J. David Bleich and R. Eliezer Waldenberg all reject any inherent place of brain death within a halakhic determination of death. R. Feinstein’s written record, which R. Shabtai examines in five exhaustive (and exhausting) chapters, remains ambiguous but the Israeli Chief Rabbinate is clear in endorsing a definition of death based on the irreversible cessation of breathing. This position effectively accepts brain stem death because a person in such a condition cannot independently regulate breath. R. Waldenberg defines death based on the irreversible cessation of heartbeat while R. Bleich utilizes a comprehensive concept of “vital motion.” According to neither of these two latter rabbis’ definitions does brain stem death qualify as death.
All of these positions are subject to medical, logical and textual challenges. R. Shabtai scrutinizes each view and, in a spirit of generally charitable reading, attempts to respond to these challenges, often successfully. Among the medical challenges are (respectively):
- Acceptance of brain stem death – Even after brain stem death, parts of the brain–most notably the hypothalamus–continue to regulate the body, thereby implying the “decapitation” is incomplete. Responses to this challenge include that all neurological functions have ceased even if hypothalamic functions continue and that the “halakhic brain” constitutes only the control center for bodily movement and not the entire brain.
- Acceptance of whole brain death – The definition of the death of every brain cell is unclear: does it mean functional (unable to use energy) or structural death (burst open or none of its contents move in a meaningful way)? What test can determine that every brain cell has died, however that is defined? And what is the halakhic definition of the “entire brain? No answers are forthcoming, which only means that the view requires further fleshing out.
- Doubtful acceptance of brain stem death – The doubt regarding brain death assumes that a brain stem dead person’s brain is similar to a gangrenous arm, lacking any blood flow. The medical reality is that blood still reaches parts of the brain. This would demand considering a brain stem dead person to be definitely alive.
- Partial acceptance of whole brain death – R. Shabtai does not challenge this view and only presents it briefly because it was written in response to short questions and does not contain a thorough analysis.
- Rejection of brain death – There is little here to challenge from a medical perspective.
R. Shabtai also subjects each view to logical tests, posing extreme cases that challenge the definitions of death. And in an extremely thorough fashion, he reviews the relevant Talmudic and halakhic texts and reveals the interpretive assumptions underlying each view, subjecting them to intense scrutiny.
R. Shabtai provides many surprises, such as R. Ovadiah Yosef’s and R. Shlomo Amar’s opposition to organ donation. However, he offers no conclusion, choosing to contribute an analysis and evaluation of existing views and not an opinion of his own. What emerges from his study is that very few rabbinic authorities would allow for the blanket consent to donate organs implied by the Facebook status. Even the Israeli Chief Rabbinate would not because it requires that a rabbi participate in the declaration of death (link).
However, the nature of this debate is set to change significantly in the upcoming years. While organ transplants are currently the only way to save thousands of dying people, the viability of artificial organs is steadily progressing. Earlier this week a permanent artificial heart was implanted into a patient in Israel (link), another in a series since the first in 2010 (link). While artificial organs have existed for decades, they have recently made great strides. The day will eventually come, if not in years then in decades, when implanting artificial organs becomes the preferred medical method. When that happens, we will no longer have to precisely define death in order to harvest organs from the dying or the dead.