Organ Donation & Brain Death in Halacha

1. Organ Donation & Brain Deathin Halacha Rabbi Henry J. Hasson, MD Assistant Professor of Neurology and Pediatrics Albert Einstein College of Medicine of Yeshiva University President, HalachicOrgan Donor Societywww.HODS.org

2. Survey • Brain Death • American Law • Jewish Law • Organ Donation • American Law • Jewish Law • Autopsy • American Law • Jewish Law • Law vs. Ethics

3. The problem • 114,000 Americans and 1,000 Israelis waiting for organs • Every year 7,000 Americans and 100 Israelis die waiting. • Israel was thrown out of European Network of Organ Sharing • Israelis and Jews are arrested every year for buying and selling organs • Jews have a bad name internationally on the issue of organ donation • In 2001, only 3% of Israelis had organ donor cards while in America it was more than 40% • Lack of Education

4. Organ Donation benefits • For Donors and Their Families • The power to save lives. Registering to become an organ donor is a charitable act that costs nothing. It allows a donor to save up to eight lives through organ donation, and to save or improve the lives of up to 50 recipients through tissue and eye donation. • The ability to comfort grieving families. It is always difficult to lose a loved one. Many grieving families of organ donors can take comfort in the fact that their loss may help to save or improve the lives of others. • For Transplant Recipients • A second chance.  For organ donor recipients, a transplant often means a second chance at life.  Vital organs such as the heart, pancreas, liver, intestines, kidneys and lungs can be transplanted to those whose organs are failing. • Improved quality of life. For some, an organ transplant means no longer having to be dependent on costly routine treatments to survive.  It allows many recipients to return to a normal lifestyle. For others, a cornea or tissue transplant means the ability to see again or the recovery of mobility and freedom from pain.

5. 12 Facts About Donationfor 2012 • One organ donor can save up to eight lives. The same donor can also save or improve the lives of up to 50 people by donating tissues and eyes. •  More than 114,000 people in the United States are waiting for organ transplants. [Solid Organs: Hearts, kidneys, pancreases, lungs, livers and intestines]. Of these, more than 8,000 live right here, in the greater New York metropolitan area. • On average, 18 people die every day while waiting for organ transplants in the U.S., and every 10 minutes, another name is added to the waiting list. In New York State, someone dies every 13 hours waiting for an organ transplant. •  Each year, more than one million people need lifesaving and life-improving tissues, and eyes.  [Tissues: Heart valves, cardiovascular tissue, bone and soft musculoskeletal tissue, and skin.] • Only 18% of New Yorkers age 18 and over have enrolled in the New York State Donate Life Registry as organ. tissue and eye donors. Nationwide, the average is 43%. •  Anytime you are in a hospital, doctors will do all they can to save your life. Donation only occurs after the death of a patient is declared by physicians who are legally not affiliated with donation. •  The factors that determine who receives an organ include severity of illness, time spent on the waiting list, and blood type. Financial or celebrity status has no bearing on determining who receives a transplant. •   Donation takes place under the same sterile conditions as any medical procedure. A donor’s body is never disfigured and donation does not interfere with funeral arrangements. Open casket services are possible. •   If you’re a donor, your family does not pay any bills related to donation.                                                                             •   All major religions support donation. •   It is illegal to buy and sell organs in the U.S. The system for matching donor organs and potential recipients is regulated by the Federal Government. •   The success rate for organ transplants is between 80 and 90 percent.

6. What Organs can be donated • Life saving Organs • Heart - A heart transplant can be used to help those suffering from heart failure, as well as babies born with heart defects. • Liver - Liver transplants may be used to treat various conditions which cause liver failure, such as cirrhosis or liver cancer. • Kidneys - A kidney transplant may be recommended for those who have been diagnosed with chronic end stage renal disease (severe kidney failure). • Lungs - Lung transplants are recommended for those with severe lung disease, such as cystic fibrosis, COPD (chronic obstructive pulmonary disease) and emphysema. • Pancreas - Pancreatic transplants are indicated for those with insulin-dependent Type I diabetes. • Intestines - Patients qualify for intestine transplants if they have been diagnosed with life-threatening intestinal diseases such as total parenteral nutrition or short-gut syndrome. • Tissues that can improve quality of life and save life as well: • Cornea -   Cornea transplants are a common procedure used to restore vision for those with eye diseases and corneal infections. • Skin - Skin transplants, referred to as skin grafts, are used to treat severe burns, extensive wounding and skin loss due to infection. • Heart Valves - Heart valve transplants are used to treat malfunctioning heart valves caused by infections, birth defects and aging. • Tendons - Tendon transplants are recommended for patients who have lost muscle function and due to nerve injury or damage to tendons.

7. When can you donate? • Living • Brain death • In the U.S., less than one percent of all deaths are brain deaths (about 15,000-20,000). • Cardiac death • bone, skin, heart valves and corneas

8. Procedures • Injuring event • Medical care attempted • Ventilator usually placed • Neurologist evaluation • Apnea test • Declared dead / brain dead • Family contacted • Decisions made

9. Some reasons why people don’t donate • I am uncomfortable with the idea emotionally • Allowing them to take organs from loved one • Making the decision • Accepting the reality • I am scared to donate due to: • Idea of needing to have organs for techiathametim • Ayin Hara / Al tiftachpehlasatan • I find it Halachically prohibited • Brain death vs cardiac death • Nivulhamet / halanathamet

10. Emotions Emotionally it is difficult however it is the right thing to do • Consider if it were the other way around and your loved one were on the receiving end. • Rav Moshe Feinstein writes • “…though it is the nature of people to be very distressed over their deceased (loved one)… nevertheless, there is a mitzvah not to be overly distressed [about donation] in order to save a life with the organ of the deceased.”(I.M. Y.D. V.III, Siman 174)

11. Ayin Hara • We believe that God is just and fair and would not allow harm to come to someone for doing a good deed • If you really believed in it you should not sign a ketuba, life insurance, health insurance, flood insurance, theft insurance, etc.

12. Tehi’at Hametim • No source in Rabbinic literature that organs are needed. • Counter-factual as all organs eventually decompose (except fossilized tzadikim) • Seems unfair to Jews incinerated in the Holocaust and injured in accidents, bombs, army, etc. • Insulting to God: if He is almighty He can resurrect you anyway • Ah Lord God! behold, Thou hast made the heaven and the earth by Thy great power and by Thy outstretched arm; there is nothing too hard for Thee (Jeremiah 32:17)

13. Jewish Ossuaries1st Century BCE – 1st Century CE During Second Temple period, Jews were buried in small stone-hewn chests, even the high priest did so. Only bones left, no organs

14. Halacha • History • 1968 Irreversible Coma/Brain Death Harvard Medical School Ad Hoc Committee 1981 Uniform Determination of Death Act - President’s Commission for the Study of Ethical Problems in Medicine 1994 American Academy of Neurology Guidelines for the determination of Brain Death • Science • Changes in science lead to changes in secular and religious law

15. Halachic issues to consider • The corpse • Nivul Hamet • Hana’at Hamet • Halanat Hamet • Giving to non-Jews • Brain Death • Is the person dead? • Can you be an organ recipient?

16. Autopsy • Rabbi Yechezkel Landau (AKA Nodah B‘Yehuda) • We can do autopsies if the results will most likely help us save someone else’s life (“choleh lefanecha”) • Rabbi Yosef Mashash • There is no disrespect to the dead in an autopsy. To the contrary, the disrespect is towards the living. The doctors do their work in secluded areas, with only medical staff in attendance, and they do it with gravitas and respect not for revenge or mutilation God forbid but only for the benefit of the public, so why would there be any prohibition in doing so? Otzar HaMikhtavim, 3 volume, ch. 1914.

17. Brain Death in Oral Torah • Mishna OhalotChapter 1, Mishna 6 אדם אינו מטמא, עד שתצא נפשו הותזו ראשיהן--אף על פי שהן מפרכסין--טמאין • Talmud Yoma 85a …תנו רבנן עד היכן הוא בודק עד חוטמו ויש אומרים עד לבו אבל לענין פקוח נפש אפי' אבא שאול מודי דעיקר חיותא באפיה הוא דכתיב )בראשית ז( כל אשר נשמת רוח חיים באפיו אמר רב פפא מחלוקת ממטה למעלה אבל ממעלה למטה כיון דבדק ליה עד חוטמו שוב אינו צריך דכתיב כל אשר נשמת רוח חיים באפיו

18. What is Brain Stem Death? Coma: Cortex is not working. Patient is not dead and he might wake up Persistent Vegetative State (PVS): aka “Vegetable” Long term coma, most likely never wake up, but still alive Life-Support Machine: Avoid using, inaccurate and it implies a football could be aliveRespirator: Avoid using it, implies spontaneous human respirationVentilator: Accurate, a machine that vents air in and out Brain Death / Brain-Stem Death: (aka Whole Brain Death) both brain-stem and cortex are dead with no chance of recovery Neurologic exam Ancillary testing

19. Brain Anatomy

20. CT scan Cerebral Anoxia Normal

21. Cerebral Angiography Normal No Intracranial Flow

22. EEG Normal Electrocerebral Silence

23. Technetium-99 Isotope Brain Scan

24. MR- Angiography

25. HODS • MISSION: • To save lives by increasing organ donations from Jews to the general population (Jews and non-Jews alike). • GOALS: • To educate Jews about the different halachic and medical issues concerning organ donation.  • To offer a unique organ donor card that enables Jews to donate organs according to their halachic belief.  • To provide rabbinic consultation and oversight for cases of organ transplantation.  • To match altruistic living kidney donors with recipients.

26. HODS Accomplishments • Israel went from 3% to 12% • Israelis dying on waiting list went from 120 a year to 80 a year • Went from 2 rabbis to 183 rabbis with organ donor cards • HODS responsible for at least 200life-saving transplants that were not otherwise going to happen

27. HODS Intervention • A 10-year-old Jewish boy was injured in a car accident in New York City. Upon arrival at the hospital he was declared dead. The HOD Society facilitated consultation with several rabbis and his family ultimately chose organ donation. Eight lives were saved. • A 21 year-old Jewish girl in a New Jersey hospital was stricken with meningitis and declared dead. Her secular parents contacted the HOD Society to learn about the halachic issues surrounding organ donation. The HOD Society enlightened the parents about the different halachic positions. Consequently, the parents donated their child’s organs. Six lives were saved.

28. Ashkenaz Rabbis Support Brain Death

29. Sephardic Rabbis Support Brain Death

30. Orthodox Doctors Support Brain Death and organ donation

31. Chief Sephardic Rabbis Support Brain Death

32. ACTION LIST • Email your family asking them what they think • Email your rabbi asking him what he thinks • Email me: henry@hassonmd.com • Consider getting an organ donor card at www.hods.org • Learn more by watching videos at www.hods.org