Judaism Organ Donation and Transplantation

What Does Judaism Have to Say About Organ Donation? Jewish law now deems organ donation an obligatory act. But this wasn't always the case.

By Rabbi Dr. Goldie Milgram, *author of Reclaiming Judaism as a Spiritual Practice, Meaning and Mitzvah, & Make Your Own Bar/Bat Mitzvah*



Depending upon your age, you might remember Jewish tradition on the topic of organ donation as very different from how it actually is today. Once opposed, Jewish law and practice on organ donation has changed dramatically, which is the beauty of Judaism as a living, evolving tradition. Now that organ transplantation is a highly successful way to save a life, organ donation has been deemed an obligatory act, a mitzvah chiyuvit, by every major branch of Judaism. Now, it is important to note that some Orthodox leaders differ on how to determine the time of death, and prefer a point later than brain death, which results in some organs being rendered unusable but even in that case, the kidneys, barring kidney disease, remain transplantable after death. Accordingly, not to bequeath your organs has become a transgression of the mitzvah of pikuakh nefesh, “saving a life.” Pikuakh nefesh, saving a life, is a primary Jewish value, and at any given minute, over 40,000 people are on the waiting list of the United Network for Organ Sharing. So what about donating an organ while alive, is that a mitzvah? So long as it will not risk your own life, surgical removal and donation of organs such as a lung or a kidney by a living donor is a mitzvah kiyumit, a praise-worthy but not obligatory mitzvah, since with all surgery there is some risk and for some, great fear. Three verses from Torah frame the source for organ donation: “You shall not stand by the blood of your neighbor” [Leviticus 19:16], “You shall surely heal” [Exodus 21:19] and “You shall restore” (a lost object, which includes someone’s health) [Exodus 23:4]. And amazingly, despite very different ways at coming to their decision – virtually the full spectrum of Judaism, with only a few rabbinic decisors dissenting, agree that post-mortem organ donation is an obligatory mitzvah. The engine of changing organ donation and transplant ethics in Judaism has been driven by the increasing transplant success rate. The procedure for most organs has rapidly shifted from experimental and life-threatening (and in that case, not permissible), to often the only possible and medically proven way to save someone’s life. Since taking the medical steps necessary to save your life if at all possible is obligatory under Jewish law and custom, accepting an organ transplant, when it would be the most effective way of extending your life, has become obligatory. With accepting a transplant having been established as permissible, next Judaism had to confront the problem of organ donation. Our tradition treats a cadaver as sacred space not to be viewed or invaded once the soul has moved on and can no longer animate that body in its own personal way. Autopsy is only allowed in Judaism under very special circumstances for this reason. So can a Jewish person’s body be used after death for medical reasons? Yes, to save a life – as in proving the facts in a murder investigation or to determine a devastating genetic disease pattern, or restore mental health to an extremely distraught family member, then autopsy is allowed. So, now that one can fulfill the mitzvah of saving a life via organ donation, Jewish legal experts reasoned, the primacy of the integrity of a body is most definitely trumped by the mitzvah of saving a life. There were more issues to work out regarding Judaism and organ donation. The freshest organs often are the most viable, but important Jewish texts and prevailing traditions seemed to call for both heart and breathing to have stopped in order for a person to be officially dead. And a donor heart must be kept pumping after brain death in order for a heart-transplant to even be possible, and keeping the heart going until the organ donation team’s work is done keeps most other organs fresher as well. Now what to do?

Authorities in Jewish medical law delved into the sources and practices condoned by gedolim, “great teachers” of traditional life such as Rabbi Moshe Feinstein and determined the actual Jewish legal criterion for death was not cessation of heart beat, but rather the permanent loss of the independent ability to breathe – which could be noticed around the chest, mouth or nose. These scholars also undertook to learn about technologies and aspects of death unknown to prior Jewish authorities, such as reliable tests for brain stem death. The research of these dedicated, observant Jewish professionals world-wide expanded to include the Chief Rabbinate of Israel which in 1986 ruled that death would be determined by these factors:

clear knowledge of the cause of injury

absolute cessation of natural breathing (not breathing that requires a respirator)

clinical proof that the brain stem is indeed dead

objective proof such as the BAER test that the brain stem is dead, and proof that numbers two and three continue for at least 12 hours under full and normal treatment.

The Hadassah Hospital criteria have been in use for heart transplants at their Ein Kerem facility in Israel since August 1987 and are widely cited and applied in healthcare settings involving Jewish patients. As mentioned above, in traditional communities, check with your rabbi before assuming they concur with this approach.

All Jewish denominations now have initiatives in place to encourage the mitzvah of organ donation. In Israel dispelling the myth that Jews aren’t allowed to donate organs has attained greater urgency. While the doctors were doing many transplants, the citizens were not donating organs and this caused such a drain on the international organization that manages organ donations, that that group simply had to cut Israel off from accessing organs pending proportionate donations of organs by Israelis.

Recently a bar mitzvah student interpreted a verse in his Torah portion, n’divat lev, “generosity of heart,” one of the conditions for the voluntary donations of the Israelites to the Mishkan (tabernacle), as meaning that every Jew would feel called to fulfill the mitzvah of organ donation. After giving his d’var Torah he asked everyone at his bar mitzvah who had either signed their organ donor card or now felt motivated to do so to rise for a blessing he would give them in honor of Torah and their commitment to applying this verse to fulfilling the mitzvah of saving a life. I asked how he came to his interpretation. His reply: “Because my little sister died for lack of an available heart. And surely, if every Jewish person fulfilled this mitzvah there would be enough hearts and organs for everyone who needs one!”

Be sure to brief your family in advance about your decision to fulfill the mitzvah of organ donation, as well as signing the back of your driver’s license to indicate this is your intention. Include this information in any legal health proxy’s you sign and put a note there “this decision is part of my commitment as a Jew to fulfill the mitzvah of pikuakh nefesh. It is permitted.” Emotions are complicated and decisions get confusing when a loved one dies. Misplaced zeal and misinformation all-too-often lead families to block a soul’s chance to fulfill this post-mortem mitzvah. There are special organ donor cards, teaching videos and excellent source articles on this subject for every kind of Jew and Jewish family to found on the web and those in traditional communities are urged to ask your rabbi about how his perspective and requirements regarding organ donation.

May you be blessed to examine your heart, to take the time to honor and overcome any inner fears or conceptual obstacles to making the mitzvah of organ donation. Remember, whoever saves one life is considered as if one had saved the entire worldą [Mishnah Sanhedrin 4:6].

Note: An earlier version of this article appeared at pjvoice.com and Rabbi Avi Shafran of the Orthodox organization known as Agudas Israel and I engaged in a political and scholarly exchange on this subject; he wanted me to know that while not the majority, there are still some in his organization who do not often permit organ donation. Here is a letter he asked to have posted as his formal response as well as my formal response to him:

What Does Judaism Have To Say About Organ Donation?
Follow up to February's Living Judaism.

-- Rabbi Avi Shafran

Reconstructionist/Renewal Rabbi Goldie Milgram asserts that authorities of halacha, or traditional Jewish law, endorse the cessation of brain stem activity as a definition of death, and consider organ donation a “mega-mitzvah.”

For accuracy’s sake and your readers’ information, both assertions are somewhat misleading. There are halachic authorities who do not accept the concept of “brain death”; so long as the heart continues to beat, these authorities assert, the person is still alive and must be maintained on life-support. They would not offer a blanket endorsement of organ donation.

There are, to be sure, cases where all would agree it is proper, even a great mitzvah, to donate one’s, or a relative’s, organs. But a halacha-respecting Jew considering such a donation, or thinking about carrying an unrestricted organ-donation card, should consult a competent halachic authority first.

-- Rabbi Avi Shafran, Director of Public Affairs, Agudath Israel of America

Rabbi Milgram responds.

I absolutely agree with and appreciate the clarifications offered by Rabbi Shafran.

Indeed, I myself have attended international Jewish bioethics conferences addressed by poskim who do not allow their constituents to utilize the criteria for death set by the Israeli Chief Rabbinate. The criteria I saw presented by such authorities do not prohibit organ donation, they do, as Rabbi Shafran indicates, require total cessation of neurological, cardiac and respiratory function, resulting in only the kidneys still being viable for transplant. The emphasis on brain stem death criteria settled on by the Israeli Chief Rabbinate allows for all otherwise-healthy organs of the deceased to be viable for transplantation.

Because of a wide-spread misperception that organ donation is never allowed in Judaism, the State of Israel became largely dependent on non-Jewish organ donors. A serious consequence was Israel's dismissal from the European Union Organ Donor Network because Israel accepted organs from the Network but did not donate organs back to the Network. Action on every Jew's part to participate in the mitzvah of pikuakh nefesh by undertaking organ donation to the extent permissible in every part of the spectrum is urgent for saving lives here, in Israel and world-wide.

As a Jewish bio-ethicist who often works with and consults Orthodox colleagues, I also respect and appreciate Rabbi Shafran underscoring that Orthodox individuals are expected to seek out the opinion of a local Orthodox biomedical Jewish law (halachic) specialist and not decide complex medical matters for themselves or with their physicians alone. The technical term for such a specialist is a posek. Each stream within Orthodoxy have preferred poskim (plural) with whom locals rabbis consult. With so many dying in Israel and the United States due to insufficient supplies of organs for transplantation, it is vital that Jews who live in accordance with Jewish law become knowledgeable about the types of circumstances under which their local Orthodox authorities permit organ transplantation and donation.

-- Rabbi Goldie Milgram, Director, ReclaimingJudaism.org