NEFROLOGIA. Vol. XIV. Suplemento 1, 1994 The body, the soul and organ donation beliefes of the major world religions A. S. Daar Dpt. of Surgery College of Medicine Sultan Qaboos University RELIG IOUS CONSIDERATIONS Questions regarding religious teachings on organ donation, particularly with respect to cadaver donation, are often raised. More often than not, however, religious constraints are more imagined than real. In the past few years a number of authors and religious authorities from the major world religions have commented on many aspects of these questions. I have tried below to capture and encapsulate the essence of those discussions relating specifically to transplantation. The major monotheistic religions of the West (Judaism, Christianity, and Islam), because of their shared origins, have similar conceptions of creation, of man's relation to God, of the material and the spiritual, of the soul, of the essential sanctity of life, and of death and eschatology. Although religious discourse, sources (canonical literature), justifications, examples used, emphases and lines of authority vary, all three religions support living organ donation, cadaver organ donation and more recently the establishment of death using brain-death criteria. All three accept that the diagnosis of physical death is best left to the physician Hinduism and Buddhism both encourage living and postmortem organ donation. However, as can be seen below, the tradition of Shinto, even though linked to Buddhist rituals, has not been able to encourage the development of cadaver organ donation in Japan; this may be a problem also in other traditions. For this reason it is discussed in some detail. judaism 1-3 Jewish law (halachah) is at once permanent (in the sense that the scriptures and Talmudic texts may not be altered) and unremittingly adaptable to s need posed by given circumstances. The important issues for debate among Rabbinic authorities have included: 1) desecration of the body after death, 2) prohibition against deriving any benefit from a corpse, and 3) responsibility to accord the deceased full burial. 78 Judaism ascribes supreme value to every moment of life, regardless of its quality or likely duration. In fact, one of the 613 commandments is the crucial commandment to save life. This overrules every other commandement except for three: i) the worship of God ii) adultery, iii) killing another person - i.e. one , may not take a life at the expense of another Transplantation of a kidney is considered a life-saving procedure (as, interestingly is corneal transplan, tation because of the Judaic statement that the blind are considered as dead) 3 Hence, the consensus is that the saving of life, limb or function is of such paramount importance that it effectively overrides these constraints provi, ded that the post mortem dono is treated with resr pect, is not mutilated and all remaining parts are buried with the deceased. Because of the absolute requirement that a Iife may not be saved at the expense of another, it is important that death of the donor should not be hastened in order to benefit the recipient. In the late 1980's there was a swing in halachic opinion towards acceptance of brain death as the decisive marking of life's termination. The Chief Rabbinate in Israel has accepted the declaration of brain death as a criterion for the establishment of death under certain conditions. In Israel, three (not two) physicians must constitute the committee, and at least one objective test must be performed. These changes now mean that Jews are not only to donate, but are to do so, i.e., it is now a mizveh, a commandment to do that (compare to "Fardh Kifaya" see under Islam below). Even the ultra ortho, dox Jews now tolerate organ transplantation. F u r t h e r m o r e Israeli law does not require consent , from the family, who only need to be informed of the intention to remove organs, but the family does have the right to object. Living donor transplantation is permitted, part of the justification being the superior results, but there is no obligation on the donor to place himself/herself at risk an living donors should not be coerced. d THE BODY. THE SOUL AND ORGAN DONATION Christianity Man was created in the image of God (imago Dei), who blew his own breath (ruach jahwe) into the body of his creature, thus transfiguring him and making man different from the rest of creation (Genesis 2,7). The body and soul together are the "person". Every human being is an individual person, independent of his social standing, achievements or health. His dignity is inalienable. The body, though, is important: it is at the core of traditional Christian belief in the Incarnation ("in flesh becoming"), the Passion, Death and Resurrection of Christ. The body will also be resurrected in the future. Therefore even though the cadaver is no longer the person, its handling requires respect, care and ritual reverentc. The voluntary readiness to donate one's organs as a means of saving the life of a sick person is not only legitimate but is a magnanimous act of charity, generosity and love and the donor acts here with ethical responsibility. The brain is neither the seat of the soul, nor the "origin" of the intellect. The Christian doctrine of the departure of the soul from the body at the moment of death would seem to support the concept of brain death. In 1957 Pope Pius XII declared that in case of prolonged coma (instances that we would now accept as brain-death) the soul might already have leit the body and no "extraordinary means" of support would be required, and he emphasised that the determination of death should be left to the physicians. On August 31, 1990 the German Bishops Conferente and the Council of the Evangelical Church in Germany published a common declaration welcoming transplantation and encouraging and justifying organ donation 7 On 20th June 1991 the Holy Father, Pope John Paul ll, delivered an address at the Vatican to the participants of the First lnternational Congress of the Society for Organ Sharing. In this extremely important address (Pope John Paul II, 1991) he made it clear that the Roman Catholic church supports organ transplantation and he concluded by quoting Jesus: "Give, and it will be given to you; good measure, pressed down, shaken together, running over, will be put in your lap" (Luke 6:38). Islam Life is sacred. It is a gift from God and is to be respected and preserved. Everything including wealth, property, family, even one's own body, belongs to Cod. Man has restricted and conditional ownership of his body with responsibilities to God (trusteeship, guardianship). This principie makes the abuse of one's own health, or one's body, a major sin. Suicide is a very grave sin. Man deserves respect, and this extends to the dead body and to the person's memory. Transplantation does not mean mutilation or demeaning of the dead body. To the contrary, it allows it to share, to give, and what is more precious to give than life? God, who is kind, compassionate and merciful, has bestowed dignity on man and given him a way of life (din: religion), which is the basis of ethical and moral behaviour. Religion is meant to provide comfort, harmony and happiness, not hardship. Disease is to be prevented, good health promoted, and life is to be preserved by all available scientific means. Any well-intended act which is safe, of benefit to mankind and unlikely to harm others is allowed unless it contradicts a basic principie of Islam. Thus medical treatment is not only a right but an obligation. Quran and Hadith are permanent. However, Islamic law, through the processes of Ijtihad (effort), Ijmaa (consensus), and specific principles of jurisprudente, is capable of evolving to meet any new situation at any time. Scholars issue "Fatwas" after careful study of any new question, e.g. transplantation, and these are meant to guide adherents. Based on severa l sayings from the Quran and the Hadith, the Islamic Code of Medical Ethics (1981) strongly approved organ donation thus: "The donation of body fluids or organs, such as blood transfusion to the bleeding or a kidney transplant to the patient with bilateral irreparable renal damage... is Fardh Kifaya, a duty that donors fulfil on behalf of society". Furthermore, "if the living are able to donate, then the dead are even more so, no harm will afflict the cadaver if the heart, kidneys, eyes or arteries are taken to be put to good use in a living person. This is indeed charity" (Kuwait document, 1981). In Egypt severa1 Fatwas by Grand Muftis have prepared the ground for transplantation: Fatwa No. 1065 of ,l959 formally allowed blood transfusion (normally considered dirty [najs] in Islam); No. 1087 of 1959 allowed cornea1 transplantation from cadavers, and this was extended by a subsequent Grand Mufti in 1966 to include other organs; No. 1323 of 1979 allowed donation of organs from the living and the dead. In Saudi Arabia, the Senior Ullamaa Commission in Fatwa No. 99 of 1982 also allowed cadaver organ donation. With regard to the question of brain death criteria, the 3rd lnternational Conference of Islamic Jurists issued in Amman, Jordan on October 1 6th, 1986, resolution No. 5, declaring the following: 79 A. S. DAAR "A person (is) considered legally dead, and all the Sharia's principles can be applied, when one of the following signs is established: 1. Complete stoppage of the heart and breathing, and the doctors decide that it is irreversible. 2. Complete stoppage of all vital functions of the brain, and the doctors decide that it is irreversible, and the brain has started to degenerate". In Saudi Arabia transplantation of kidneys from brain dead donors is practised now as a matter of routine, with the support of both the religious and political authorities. Severa1 other Muslim countries are trying to emulate their experience. 13 after death is seen as an act of generosity (alobha), w h i c h is (itself) described a) as a moral mental property contributing to the achievement of Nirvana ( P a r i n i b b a n a ) the summum bonum in Buddhism and, b) an example of compassion (karuna) one of the four guidelines to social living. Thus transplantation from the living or the dead is allowed, as is xenotransplantation. Psychological aspects need to be given particular attention, since the mental quality of the donor could influente the recipient's course. Shinto Shinto is as old as Japanese culture and as a religion gives both ethics and ethnic identity to the Japanese. In Japan, Buddhism itself has been influenced by the native Shinto tradition and by other Japanese folk beliefs, which are different from those of China or Korea. In Shint'o, the central value is purity: all gods are pleased with purity and angered by impurity and pollution. Death is the ultimate polluted matter. The dead body is so impure, polluted and dangerous that it must be expelled quickly; and contaminated persons and things must be decontaminated by specific purification rites. The dead body is so impure, in fact, that Shinto has not even developed theories or rites to handle it, but Buddhism has developed rituals and ceremonies for the dead and it is these which are used in Shinto. The dead, however, go on to become deified in the system of ancestor worship (Shinto is theanthropic). Dead spirits are worshipped for either 33 or 49 years, after which they lose their personal identity, become extremely pure, and end up as the community's guardian gods, who are then worshipped as such. Amaterasu, the god of the sun and also the paramount god of Shinto, is believed to be the primary ancester of the Japanese Royal Family. The word "itai" (the remains), as opposed to "shitai" (the dead body) embraces a sense of identification of a continuing relationship between the bereaved and the recently dead person. Itai (or "go-itai" to indicate politeness and respect) has its own hopes and requests and in order to avoid misfortune, the bereaved must not only guess and grant these requests but also avoid any injury to itai. It thus becomes clear why it is difficult in Japan to obtain consent from bereaved families for organ donation, dissection or diagnostic post mortem examinations: these are all regarded as injury to itai. In fact, even if a person has indicated a willingness to donate his body to a medical school, the family often refuse consent for dissection. They do this because they want to avoid injury to the itai by their own will, as this injury to the itai Hinduism The main philosophy of the religion is based on "The Law of Karma" and reincarnation. This has direct relevance to transplantation. The soul is immortal, occupying a new body with each incarnation, but without erasure of the experiences of previous births. The physical body, because it is made of the basic universal elements of earth, water and air should be returned to these basic elements through cremation. However, the dead are respected and gracefully mourned, and the body must be respected, cleaned and escorted for cremation. Hindu mythology contains traditions whereby human body parts were used to benefit other human and society. There is nothing in the religion to indicate that organs from either the living or postmortem donor could not be used to alleviate suffering, especially as one of the basic themes of the Hindu religion is to help those who are suffering. The Lord Krishna has said that whatever we do today will decide what we will become tomorrow. Thus religion per se is unlikely to contraindicate cadaveric donation in India. 14 Budism At the absolute level, the body is but a conglomeration of matter and mind and any sense of permanente is but an illusion, as is our notion of life itself. Death is the "temporary end of a temporary phenomenon", to b e followed by rebirth, when there is a new mind/body partnership. Thus there is nothing intrinsically sacrosanct or holy about the human body, alive or dead, and its disposal after death does not make much difference. However, the ideal of the social good (attha samhita) encourages the decent treatment of the dead for reasons of love, respect, gratitude or example. Donation for transplantation while alive or 80 THE BODY, THE SOUL AND ORGAN DONATION makes the dead pe rson's soul more miserable than Ignoring the person' s living will Bibliografía 1. Weiss DM: Organ transplantation, medical ethics and Jewish Law. Transplant P r o c 20:1071-1075, 1988. 2. Bulka Rabbi RP: Jewish perspective on organ transplantation. Transplant Proc 22:945-946, 1990. Aiallam: General discussion on the dilema of post mortem organ donation. In: Organ Replacement Therapy: Ethics, Justice & Commerce (eds.: Lan W and Dossetor JB). Springer-Verlag, Berlin, 319-320, 1991. Scorsone S: Christianity and the significance of the human body. Transplant Proc 22:943-944, 1990 . . Sass HM: Philosophical arguments in accepting brain death criteria. In: Organ Replacement Therapy: Ethics, Justice & Commerce (eds.: Land W and Dossetor JB). Springer-Verlag, Berlin, 249-258, 1991. 6. Angstwurm H: Brain death as death of a human being: a matter of image of man. In: Organ Replacement Therapy: Ethics, Justice & Commerce (eds.: Land W and Dossetor JB). SpringerVerlag, Berlin, 241-244, 1991. 7. Grundel J: Theological aspects of brain death with regard to the death of a person. In: Organ Replacement Therapy: Ethics, J u s t i c e & C o m m e r c e ( e d s .: Land W and Dossetor JB). Springer-Verlag, Berlin, 245-248, 1991. 8. P e o B: Organ transplantation: a Christian viewpoint. Transplant Proc 24 (5):21 14-2115, 1992. 9. S a c h e d i n a AA: Islamic views on organ transplantation. T r a n s p l a n t Proc 20:1084-1088, 1988. 10. Sahin AF: Islamic transplantation ethics. Transplant Proc 22:939, 1990. 11. A l Bar MA: Islamic view of organ transplantation. 2 n d International Conf. Middle East Soc Organ Transpl Kuwait. March 11 -15 1990. Eds.: Abouna GM, Kumar MSA, White AG. Kluwer Academic Publishers. Dordrecht, Netherlands, pp. 563-578, 1991. 12. Daar AS: Current practice and the legal, ethical and religious status of postmortem organ donation in the Islamic world. In: O r g a n Replacement Therapy; Ethics, Justice & Commerce. (ed: Land W and Dossetor JB). Springer-Verlag, Berlin, 291299, 1991. 13. Trivedi HL: Hindu religious view in context of transplantation of organs from cadavers. Transplant Proc 22:942, 1990. 14. Sugunasiri SHJ: The Buddhist view concerning the dead body. Transplant Proc 22:957-959, 1990. 81