Donating in good faith or getting into trouble Religion and organ donation revisited

Abstract

There is worldwide shortage of organs for solid-organ transplantation. Many obstacles to deceased and live donation have been described and addressed, such as lack of understanding of the medical process, the issue of the definition of brain death, public awareness of the need for transplants, and many others. However, it is clear that the striking differences in deceased and live donation rates between different countries are only partly explained by these factors and many cultural and social reasons have been invoked to explain these observations. We believe that one obstacle to both deceased and live donation that is less well appreciated is that of religious concerns. Looking at the major faiths and religions worldwide, it is reassuring to see that most of them encourage donation. However, there is also scepticism amongst some of them, often relating to the concept of brain death and/or the processes surrounding death itself. It is worthwhile for transplant teams to be broadly aware of the issues and also to be mindful of resources for counselling. We believe that increased awareness of these issues within the transplant community will enable us to discuss these openly with patients, if they so wish.

Key Words: Organ donation; Transplantation; Religion

INTRODUCTION

Chronic shortage of organ donors has led to an ever-increasing disparity between supply and demand. One particularly challenging issue in Europe and the United States is that of organ donation to and from patients from ethnic minorities: Many of these patients carry an above-average risk of developing end stage renal failure[1]. Unfortunately, this patient group is not only statistically less likely to receive a well matched organ on the deceased waiting list but also less likely to volunteer as live donors[2]. Such patients with prolonged waiting times may result in them becoming a growing burden on dialysis programs, leading to adverse clinical outcomes. Others have previously emphasised that this might also lead to resentment and the temptation into organ trafficking[3]. We became interested in this topic during our own clinical work serving a varied population in the North West of England. We were intrigued by the fact that a substantial number of patients cited religious concerns as the reason not to go ahead with live donation. We felt that in comparison to other, well described barriers to donation, religious concerns are generally not well appreciated within the transplant community and we sought to explore this issue further. Here, we aim to provide a brief overview of how religious barriers may arise and how the transplant community and society at large might address them in the future.

CHRISTIANITY

Generally, there is a widespread belief amongst the Christian faith that organ donation is a worthwhile act of altruism although the decisions that accompany this should be left to an individual[4]. As far as we can gather, most Christian faiths are therefore openly supportive or at give their tacit approval. As for Catholicism, we know that the current Pope Benedict XVI is an open advocate of organ donation, having had a donor card himself[5] ever since the 1970s. Interestingly, it has recently transpired that his decision to donate may be merely theoretical, since Vatican officials say that after a Pope dies, his body must be buried intact[6]. The Church of England has even gone so far as to declare organ donation a Christian duty[4]. Some small Christian sub-groups have taken this idea even further to actively promote and expect altruistic donation amongst their followers[7].

JEHOVAH’S WITNESSES

Jehovah’s witnesses are a group of Christian denomination distinct from mainstream Christianity. The idea that Jehovah’s witnesses will not accept blood products obviously complicates the issue of transplantation greatly[8]. Cellsaver techniques, in which the patient’s own blood is re-infused during a procedure, are allowed, but transfusion of a pre-surgically donated unit of blood is not[9]. In the 1960s, this religious group issued statements declaring transplantation as cannibalistic. This view was only revisited and essentially rescinded in the 1980s[10]. Current views leave the decision to the individual, provided that no blood is transplanted. Consequently there have only been small case series in this patient group[11]. Some transplant centres require patients to allow emergency transfusion and some authors have proposed that such contracts should be mandatory before transplantation[11].

This scenario is ethically complex and its discussion is clearly beyond the scope of our little comment. Clearly, such contracts can be seen as coercion. Transplant centres should be encouraged to have an open and honest discussion within the team on this topic to see whether they are prepared, or not, to accept the increased risk with, for example, renal transplantation without the option for rescue transfusion. We believe that it would be difficult to categorically deny Jehova’s witnesses the option of transplantation, as long as their medical team accepts the increased risk and provided that all options and risks have been openly discussed. We would also argue that this situation is not fundamentally different from a transplant centre accepting other high risk transplant candidates.

ISLAM

Whosoever saves the life of one person, it would be as if he saved the life of all mankind. This Qur’an passage highlights a key principle of Islam. The converse of this is that violating the human body is strictly forbidden in Islam. These contradictions have been discussed repeatedly by Islam scholars. In 1996 the United Kingdom Muslim Law Council ruled that organ transplantation is entirely in keeping with Islam[12] and other, similarly proactive declarations have emerged elsewhere. Nonetheless, and despite repeated attempts by Islam scholars to promote organ donation, many individual Muslims are still reluctant to accept the concept, particularly deceased donation[13]. As of today, most transplants in predominantly Muslim countries are therefore live donations although it is not clear whether this is solely due to religious concerns. Logistical problems are also highly prevalent in many of these countries and they, too, impede the establishment of national systems for deceased donation. It is also worthwhile to note that there are nuances as to the views taken by Muslims in different countries. Indo-Asian Muslims, for example, seem to be more reluctant to accept deceased donation than Muslims from Arab countries[10]. It is worthwhile to note that religious concerns are equally important in Muslims living in Western countries: A recent survey confirmed this and reported that only 39% of Western Muslims surveyed felt that organ donation is in keeping with Islam[3].

JUDAISM

Traditionally, when a member of the Jewish faith dies, burial should take place within 24 h and should never be delayed. Desecration of the cadaver, for what ever reason is frowned upon as is the ‘receiving of any benefit from the dead[14]. As with other religions, the definition of brain death is particularly problematic in that the traditional Jewish definition of death requires that all brain, respiratory and cardiac output have ceased. Jewish faith also stipulates that organs are treated respectfully[14]. If an organ is not used at transplantation after removal from the body, it should not simply be discarded.

In Israel, where 75% of the population are of the Jewish faith, only around 10% of the population are in possession of an organ donor card and the deceased donation rate is as low as 9 per million population (2004 data[10]). The Israeli government has attempted to alleviate the issue with two laws in 2008, firstly to define the time of death and secondly to award a broad range of benefits to live donors. Parts of the ultra-orthodox community have responded to this new law by issuing anti-donation cards[15]. The cards read: “I do not give my permission to take from me, not in life or in death, any organ or part of my body for any purpose.”[15].

Other religious authorities take a different, proactive view, most notably the Halachic Organ Donor Society (HODS). Uniquely, HODS offers two optional definitions of death on their organ donor cards, namely that of brain stem death as well as that of cessation of heartbeat[14]. HODS has also managed to enlist support of a large number of Rabbis, many of them from orthodox quarters. Their organ donor cards are on display on the HODS website[16].

Again, uniquely, the Israel Transplant centre allows registered donors to stipulate that a named religious scholar be consulted before donation can go ahead (Figure 1). Some have regarded this clause as highly problematic, given that in Israel preference in the transplant waiting list is given to potential recipients who have signed an organ donor card themselves. Accordingly, people who do no genuinely intend to donate organs would receive preferential treatment as transplant recipients, while in the event of their own death their religious patron could veto donation.

Figure 1 Donor declaration, Israel Transplant Centre, including an optional clause that a religious scholar must be consulted before transplantation can go ahead.

HINDUISM, SIKHISM AND BHUDDISM

The very ethos of Hinduism supports the idea that the physical integrity of the body post-death is not crucial. Hinduism is the predominant religion in South Asia, with around 1 billion followers. Hindus believe in reincarnation as well as any means whereby life can be prolonged or sustained. These principles therefore lend themselves easily to the idea of transplantation[17] and we are not aware of any particular problems regarding organ donation.

The word Sikh implies learner. The ethos of a Sikh is that religion should be practiced in the living world by dealing with life’s day to day problems. Sikhs believe in life after death and a continuous cycle of rebirth. The physical body is not viewed as important in this process but the idea of doing good actions is[18]. Again, transplantation is viewed positively amongst the Sikh community.

In Buddhism, the death process is viewed as an important time and some followers are of the opinion that some form of spiritual consciousness remains alive in the body for days after death. These views have led to some contradictions regarding donation from the Buddhist community, mainly surrounding issues with regards to brain stem death diagnosis. These points directly rival the Buddhist ideologies of selflessness and giving to another[19].

CONFUCIANISM, SHINTOISM AND TAOISM

From the Western point of view it is difficult to say whether Confucianism is a religion as such or an ethical and philosophical system and school of thought. However, mainland China, Taiwan and Korea are countries strongly influenced by the teachings of this important Chinese philosopher. Some teachings of Confucian origin suggest that one is born with a complete body and should die this way[10]. However, modern Confucians acknowledge that to sustain the life of another is a valued thing. Interestingly, recent data from Korea suggest that there is still some conflict amongst young Koreans as to the appropriateness of transplantation in a Confucian society[20]. One of the key principles of Confucian society is the deep respect for parents. This could be a factor when family are faced with the decision or not to allow their parent’s organs to be donated.

Shinto is the indigenous spirituality of Japan and the people of Japan. Shinto’s believe that the body is pure and gathers impurities throughout life. A cadaver is considered very powerful and can impose bad luck if interfered with. Incredibly, organ procurement from “brain dead” donors was only legalized in 1997[21] and it took another 2 years until in 1999 a heart transplant was performed. Although deceased donation is now legal in Japan, the country continues to have a very low rate of deceased donation. To overcome this problem, Japan developed one of the first ABO incompatible transplant schemes[22].

Taoism is a philosophical tradition from Eastern Asia whose stance on transplantation essentially revolves around the ethos that changes made to Human form cannot truly affect the essence of life. Organ donation is therefore generally approved.

DISCUSSION

Religious views on organ donation are very diverse, ranging from almost complete opposition (as in the ultra-orthodox Haredim) to profound scepticism (as in parts of the Indo-Asian Muslim community), to a proactive, supporting stance, as in Hinduism or Christianity. Some religious authorities, such as HODS, have found ways to accommodate different views regarding this issue, such as the two-tier organ donor card.

We also need to acknowledge that the scriptures around which the different faiths are based do not specifically mention the transplantation of organs. Different scholars and schools of thought within a faith or religion may therefore arrive at different conclusions when interpreting these scriptures. Accordingly, views may differ considerably within one particular faith or between religious scholars and communities. A good example is that of Muslims in Western countries, such as the United Kingdom: Many Muslims in the United Kingdom are not fully aware that the Muslim Law council of Great Britain has explicitly advocated deceased donor transplantation as a means of saving life. The council accepts the medical diagnosis of brain stem death for the purposes of transplantation. The discrepancy between the rulings of Muslim scholars and the views of patients and relatives is clearly evident in our own day-to-day experience in the North-West of England and in recent surveys[3]. Another good example of different opinions within the spectrum of one faith is Judaism whereby organisations such as HODS take a proactive and to some degree pragmatic view whereas orthodox and ultra-orthodox quarters remain at least deeply sceptical if not opposed.

CONCLUSION

To conclude, we acknowledge that the impact of one’s religion on the decision to go ahead with deceased or live donation is perhaps under-recognised. We speculate that religious concerns play a role in many decisions against donation. We find it reassuring that all large world religions approve of organ donation, and that most religious rules and concerns are overcome by the over-arching principle of altruism. Ideally further education of physicians likely to be faced with these types of dilemmas should be undertaken and new community-based approaches are required to deal with religious concerns in organ donation. Transplant physicians and surgeons need to acquire some knowledge on this topic and Inter-faith initiatives, such as the National Donor Sabbath in the United States[23] (Figure 2), or the “Wall of Life” initiative in the United Kingdom are particularly welcome.

Figure 2 Promotional material for National Donor Sabbath in Illinois, United States. This is part of an organ donation initiative coordinated by Donate Life America, a not-for-profit alliance of national organizations and state teams across the United States committed to increasing organ, eye and tissue donation. Observed on Friday through Sunday two weekends before Thanksgiving, the 3-d period seeks to include the days of worship of major religions practiced in the United States Courtesy of Donate Life Illinois.