Religious Concepts in Organ Transplantation

Abstract

Beside cultural, social, and educational issues, religious beliefs are assumed to play a significant role on the attitude towards organ transplantation much more often than clinicians believe. At the same time, health-care providers may lack sufficient knowledge on religious issues pertaining to transplantation.

1. Introduction

One of the most touching forms of human compassion is related to the transplantation of human organs from a mother to a son, from a father to daughter, from a brother to a sister, from a friend to a friend, and from a stranger to a stranger.

Organ donation, from both living and deceased donors, is considered by most religions as an expression of the believer’s altruism, generosity, duty, charity, and cooperation as long as the following conditions are fulfilled [1]:

1. The procedure occurs in the context of respect for the dignity of the dead person.

2. Organs from deceased donors are removed only after certain death has be confirmed.

3. Live organ donation does not impede the life of the donor.

4. Organ donations are given as a free gift without reward.

5. Commercialization and/or considering organs as items for trade or exchange are prohibited.

However, there are different schools of thought, between different religions and within each religion, regarding the issue of transplantation of human organs. In fact, religious concerns are considered by many as an important reason that explains why many individuals decline deceased and live organ donation and/or the willingness to accept a transplant.

2. Concerns around brain death

There are concerns and uncertainty regarding the issue of brain death. For example, some Muslim scholars, Orthodox Jews, Catholic theologians, and Buddhist scholars do not accept the concept of brain death [2].

3. Religiosity and willingness to donate

Religious views have been identified as a factor influencing the willingness to donate, with religion tending to be cited as a barrier to donation. Those who are described as being more religious may be less likely to support donation, believing that their religions oppose donation. In fact, most of the negative attitudes towards organ transplantation may be due to the uncertainty about the religious stance rather than the interpretations of religious teachings. The conservativeness of religious belief, rather than religiosity itself, may be the underlying factor against donation [3].

Negative attitudes are also related to how the individual interprets his or her relationship with God at the times of sickness. The response to illness is that it is God’s will and they have to accept. Therefore, organ donation may conflict with the belief that one should respect God’s will [4].

4. Body integrity

The importance of body integrity is much related to religious and cultural beliefs. The belief of being resurrected in the afterlife and the need for own organs after death is an obstacle against organ donation. Showing respect to the deceased individual may be also a barrier against donation. Dissecting the body is commonly perceived as a violation, believing that the deceased person could still feel pain [5].

5. Funeral

The expectation that the process of organ donation will delay funeral and prevent it from proceeding in the traditional way may also be a factor explaining negative attitudes against deceased organ donation [6].

6. Interplay of religious and cultural beliefs

There are striking differences between countries as to the willingness to donate. Besides the religious factors, some of the differences could be attributed to different infrastructure, law, and consent systems. At the same time, the interplay between religious and cultural beliefs is also an important factor. Barriers to organ donation that are perceived as religious may actually reflect cultural attitudes that transcend religion [7].

7. Directed donation and religion

This is defined as organ donation directed to a group of recipients determined by the presence or absence of a particular characteristic, such as ethnicity, religion, age, or gender. Most transplant centers emphasize unconditional altruism as the fundamental principle of deceased organ transplantation and do not allow directed deceased donation [8].

8. Attitudes of different religions towards organ transplantation

8.1. Christianity and organ donation

The predominantly Christian countries of Europe and America have higher rates of organ donation [9]. However, there is no conclusive evidence regarding the role of the Christian religion as regards to its influence on the willingness to organ donation. It is the strength of religious belief and the interpretation of individual relationship to God, rather than the teachings of the faith, that will influence the attitudes towards organ donation [10].

Christians believe in eternal life and that nothing that may happen to the body, before or after death, would impair the relationship with God. “In eternity we will neither have nor need our earthly bodies: former things will pass away, all things will be made new” (Revelation 21: 4–5).

The cross (Figure 1), a central Christian symbol, is about Jesus giving for the salvation of the world. The Christian faith is based upon the revelation of God in the life of Jesus Christ. John 3:16 says, “God so loved the world that God gave his only son. Jesus sent his twelve disciples out with the imperative to heal disease and illness: “Heal the sick…freely ye have received, freely give” (Matthew 10:8). Healing and saving life is a great gift.

Figure 1.

The cross, the central Christian symbol.

On this basis, organ donation to save other lives is considered to be the ultimate humanitarian act, and with this understanding, donating organs for transplantation is acceptable in terms of moral Christian law. On the contrary, organ donation is not morally allowed if the donor or his proxy has not given formal and clear consent. At the same time, it is not acceptable to cause death or mutilation of a human being to delay the death of another person [10].

8.1.1. Catholicism and organ donation

Roman Catholicism is the largest Christian denomination in Europe. Almost half of the European Union population consider themselves Catholic. It has been noticed that countries with a higher proportion of Catholics have higher rates of deceased organ donation [9]. Many Catholics view organ donation as an act of charity and love. In fact, Catholicism is one of many factors that predict willingness to organ donation, and making a causal link between Catholicism and donation is difficult [10].

The Vatican considers both organ donation and transplantation morally acceptable and encourages organ donation [11]. In 1956, Pope Pius XII [12] (Figure 2) declared that: “A person may will to dispose his body and destine it to ends that are useful, morally irreproachable and even noble, among them is the desire to aid the sick and suffering…this decision should not be condemned but positively justified.” In August 2000, Pope John Paul II (Figure 3) told attendees at the International Congress on Transplants in Rome that “Transplants are a great step forward in science” and stated that “the Catholic Church would promote the fact that there is a need for organ donors and that Christians should accept this as a ‘challenge to their generosity and fraternal love’ so long as ethical principles are followed.” Lately, in October 2014, Pope Francis described the act of organ donation as “a testimony of love for our neighbor”.

Figure 2.

Pope Pius XII.

Figure 3.

Pope John Paul II.

8.1.2. Orthodox Christian Church

In the Orthodox Church tradition, organ donation could be considered as an act of charity. If the donor is living, the decision to donate an organ should be made in consultation with the spiritual father and the medical professionals. Deceased organ donation is also an act of charity that helps to make possible a sick patient to live a longer and better life. Organ donation is acceptable only if the deceased donor had willed such donation or if the relatives permit. The body of the donor should be treated respectfully. Organ transplantation should never be commercialized nor taken place without clear consent. The death of the donor should never be hastened to recover organs for transplantation [13].

8.1.3. Protestantism

Because of the many different Protestant denominations, a generalized statement on their views regarding organ donation and transplantation cannot be made. The Protestant faith shares a common belief in the New Testament (Luke 6:38: “Give to others and God will give to you.”) and respects individual conscience and the right to make decisions regarding the person’s own body. It is generally not believed that resurrection requires making the body whole again. Most Protestant Churches encourage the spirit of generosity of organ and tissue donation [14].

Churches, such as African Methodist Episcopal (AME) and African Methodist Episcopal Zion (AME Zion), Assembly of God, Brethren, Christian Church (Disciples of Christ), Church of the Nazarene, Episcopal, Evangelical Covenant Church, Evangelical Lutheran Church in America, Lutheran Missouri Synod, Mormon (Church of Jesus Christ of Latter-day Saints), Presbyterians, Unitarian Universalist, United Church of Christ, and United Methodist Church, are highly supportive of donation. They encourage their members to consider the possibility of organ donation as an act of Christian love. However, the decision to donate is left to each individual [15, 16].

On the contrary, Churches, such as, Unitarian Universalism, Southern Baptist Convention, Society of Friends (Quakers), Pentecostals, Mennonite, Moravians, Christian Science, and Amish, have no official position on organ donation and consider that there are no spiritual or theological beliefs that would prevent an individual from donating. They believe that the decision to donate is up to the individual and/or his or her family [15, 16].

8.1.4. Jehovah’s Witnesses

Jehovah’s Witnesses are a non-Trinitarian Christian denomination. They are distinct from the mainstream Christianity. The issue of transplantation is compounded by their refusal of blood transfusion. This includes full blood, platelets, and plasma. On the contrary, dialysis, plasma exchange, albumin, clotting factors, and erythropoietin infusions are all allowed [17].

Jehovah’s Witnesses are often assumed to oppose organ donation because of their belief against blood transfusion. However, this merely means that all blood must be removed from the organs and tissues before being transplanted (Office of Public Information for Jehovah’s Witnesses, October 20, 2005). Some have argued that consent to rescue transfusion should be a prerequisite for transplant listing [18].

Organ transplantation was not allowed for Jehovah’s Witnesses until recently. The religious guidance from the 1960s stated that those who submit to human organ transplantation are living off the flesh of other humans. That is cannibalistic. Jehovah God does not grant permission for humans to perpetuate their lives by cannibalistically taking into their bodies’ human flesh. This view was only revised in the 1980s, and the decision for or against transplantation is regarded as an individual choice under the assumption that no blood is transfused. Small series of kidney and pancreas transplants in Jehovah’s Witnesses have been described. Early postoperative deaths in anemic cases have been reported [19].

8.2. Islam and organ donation

When a Muslim dies, it is a religious requirement that the body is ritually washed and draped and the corpse is buried. Cremation is not allowed in Islam. Washing and shrouding is carried out by respected persons of the same sex as the deceased, who is experienced in the rules of Muslim burial. All clothes are removed and the body is covered. Private parts are covered with a sheet and never exposed during the wash [20]. Muslims are buried in such a way that the face of the deceased faces Mecca. The arms and legs should be straightened and the mouth and eyes are closed. Muslims believe in the Day of Judgment and the afterlife. It is a religious recommendation that an ill person, whether a relative or a stranger, be visited. This is considered a form of worship. It is traditional for Muslims to be buried as quickly as possible. Violating the human body, whether living or dead, is forbidden in Islam [21].

Muslim laws (Shari’ah) are derived from Koran and Hadith (practices and sayings of the prophet Mohammed). Islam recognizes no intermediary between humans and God, such as a clergy. High-ranking Muslim jurists (Ulamas) help Muslims on the interpretation of the Koran and the Hadith. Organ transplantation has not been dealt with in the Koran or the Hadith, and there is a difference of opinion among the Ulamas. The majority of Islamic scholars have concluded that organ donation as treatment for otherwise lethal disease is a good and faithful thing [22].

Islam considers that life is sacred and it must be preserved by all possible means, and one of the basic rules in Islam is the saving of human life. This is a fundamental aim of Islam. Many Muslim scholars consider organ donation as an expression of the believer’s altruism, generosity, duty, charity, cooperation, etc. [23].

Although, in Islam, violating the human body, whether living or dead, is greatly forbidden, this prohibition may be waived in the cases of necessity, such as saving a human’s life. The fundamental Islamic rule that “necessities permit the prohibited” (al-darurat tubih al-mahzurat) will support donation of both living and deceased human organs by saving a life of another because the benefit outweighs the cost that has to be paid [24].

The following are some verses that have been used to support organ donation:

1. “Whosoever saves the life of one person it would be as if he saved the life of all mankind.” Holy Qur’an, chapter 5 vs. 32 (Figure 4).

2. “Whosoever helps another will be granted help from Allah.”—Prophet Mohammed (PBUH)

Figure 4.

Holy Qur’an, chapter 5 vs. 32: “Whosoever saves the life of one person it would be as if he saved the life of all mankind.”

Most of the major academies of the Muslim world support organ transplantation as a means of alleviating pain or saving lives and encourage Muslims to donate organs for transplantation [25]. These include the following:

1. Al-Azhar Academy of Egypt,

2. The Organization of Islamic Conference (representing all Muslim countries).

3. The Grand Ulamas Council of Saudi Arabia, and

4. The Iranian Religious Authority.

In 1952, the supreme head of the Islamic School of Jurisprudence in Egypt stated that if anything was of “good” for mankind, then “necessity allows what is prohibited.” Such rulings allow transplants of organs as long as the following conditions are satisfied [24]:

1. This is the only form of treatment available.

2. The likelihood of success of the transplant is high.

3. The consent of the donor is obtained.

4. The death of the donor has been fully confirmed, in the case of deceased donors.

5. There is no imminent danger to the life of the donor, in the case of living donors.

6. The recipient has been informed of the operation and its implications.

The Islamic Jurisprudence Assembly Council in Saudi Arabia approved deceased and live donations in 1988. Similar rulings are in place in, among other countries, Egypt, Iran, and Pakistan [25].

Islam, as all religions, is not monolithic. Some of Muslim scholars are less approving of organ donation. Various reasons are given for the skepticism. These include the following [26]:

1. The thought that the human body is entrusted to man and man is not allowed to interfere with.

2. The human body has a special honor, and violating the human body, whether living or dead, is greatly forbidden. This is supported by the words of the Prophet Mohammed (PBUH): “The breaking of a bone of a dead person is equal in sin to doing this while he was alive.”

3. The concept and definition of brain stem death is still controversial.

It is also important to mention that religious concerns play a role even among Muslim physicians.

8.3. Judaism and organ donation

Figure 5.

The seven-branched menorah, a traditional symbol of Judaism.

Judaism religion stresses on the honor and respect of the dead (kavod hamet). According to Solomon, the following three Jewish principles should be followed in the treatment of the body after death [27]:

1. Respect and dignity to a cadaver,

2. Not benefiting from a corpse, and

3. Immediate burial.

At the same time, many Jewish scholars disagree to accept the concept of brain death. In fact, Halachic guidance, which is so important in Judaism faith, is not settled to whether the Jewish law considers a person dead or not when the whole brain dies or when the heart stops beating. A Goses, a Halachic term describing a person who is critically ill and likely to die within 3 days, must not be interfered with in order not to hasten death. Therefore, there may be reluctance to medically interfere with a dying patient for the purpose of preparing for organ donation [28].

On the contrary, saving a life is a fundamental value in Judaism (pikuach nefesh). Many Jewish scholars state that the urge to save lives overrides the above-mentioned concerns. In fact, Jewish law mandates that, to save a life, one may violate almost all commandments (except for the prohibitions of murder, idolatry, and illicit sexual relations). This guidance has been used to support the concept organ donation, as it results in saving lives [29].

The Jewish principles of saving a life (pikauch nefesh) and the respect to the dead (kavod hamed), therefore, may come into conflict with one another considering the organ donation [29].

Rabbi Elliott N. Dorff, a professor of Jewish theology at the American Jewish University (formerly the University of Judaism) in California, an author and a bioethicist, wrote: “Saving lives by organ donation could override the rules concerning treatment of a dead body. Transplantation neither desecrates nor disrespects the dead body, and the delay in burial to facilitate organ donation is respectful to the decedent. Organ donation honors the deceased as it would save a life” [30].

At the same time, the Conservative Movement’s Committee on Jewish Laws and Standards argued that deceased organ donation for transplantation represents not only an act of generosity but are also a “commanded obligation,” which could save a human life. “Do not stand idly by your neighbor’s blood” (Leviticus 19:16), which directs we use any resource possible to save a life [29, 30].

Another question is whether or not a kidney transplantation is truly life saving, so long survival on dialysis is possible, and whether corneal transplantation, which is not life saving, is justified. Some Jewish scholars argue that blindness is nearly similar to death, and corneal transplantation is Halachicly acceptable [28].

The important question is whether or not the Jewish law considers someone dead when the whole brain dies or when the heart stops beating. There are scholars on both sides of the question. For this reason, uniquely, the donor card issued by the Halachic Organ Donor Society provides two options, i.e., donation after brain death and/or after cardiac arrest [31].

Disagreements between rabbinic authorities and physicians on the concept of brain death were only settled in 2008, when a new Organ Transplant Law in Israel was approved. However, refusal to the acceptance of brain death remains, and not all rabbinic authorities approve it [30].

8.4. Buddhism

Organ donation rates, in the predominantly Buddhist countries of Southeast Asia particularly in Thailand, Cambodia, Singapore, and Vietnam, are low. Beside the religious barriers, cultural barriers to donation also exist due to a lack of acceptance of brain death [32].

Central to the faith of Buddhism is the idea that all of life is suffering (dukkha). This suffering can be overcome by an eightfold path of virtues. Buddhism considers everything on earth transitory and believes in rebirth. In Buddhism tradition, the time of death is very important and should be treated with great respect. The concept of brain death is doubted, and according to some Buddhism traditions, the spiritual “consciousness” will remain in the body for days after cessation of breathing. The departure of this spirit is the actual moment of death. Until then, the body must remain undisturbed. Disturbance of this process may adversely affect the individual’s next rebirth. In other words, the moment of death is defined according to criteria very different from those of modern Western medicine [33].

Figure 6.

Drawing of Buddha face.

The above-mentioned considerations are in conflict with generosity (dāna) or selfless giving. Dāna is central to Buddhism faith. It entails the wish to relieve suffering; therefore, there may be circumstances where organ donation may be seen as an act of generosity [34]. Buddha (Figure 6) said to his monks, when he discovered a sick monk, “Whoever would care for me, let him care for those who are sick” [Mahavagga VIII.26.1-8 (Kucchivikara-vatthu—The Monk with Dysentery, translated from the Pali by Thanissaro Bhikkhu)] [35]. Reverend Gyomay, President and Founder of the Buddhist Temple of Chicago said, “We honor those people who donate their bodies and organs to the advancement of medical science and to saving lives.”

Overall, it is probably a mixture of beliefs within the East Asian tradition rather than the true Buddhist beliefs that influence the attitudes towards organ donation and transplantation [33].

8.5. Hinduism

Hinduism is the predominant religion in South Asia with approximately 1 billion followers. Hindus believe in the transmigration of the soul and that the deeds of an individual in the present life will eventually determine its fate in the next life. In the Hindu faith, life is an ongoing process of rebirth after death. The law of Karma determines the way the soul will go in the next life. The Bhagavad Gita, a narrative framework of a dialogue between Pandava prince Arjuna and his guide and charioteer Lord Krishna (Figure 7), describes the mortal body and the immortal soul like the relation of clothes to a body: “vasamsi jirnani yatha vihaya navani grhnati naro ‘parani tatha sarirani vihaya jirnany anyani samyati navandi dehi.’” “As a person puts on new garments giving up the old ones the soul accepts new material body giving up the old one” (Bhagavad Gita chapter 2:22). The physical integrity of the dead body is not seen as crucial to reincarnation of the soul [36].

Figure 7.

A page from Bhagavad Gita: “Those who are faithful do not grieve for the dead or for the living. Neither I, you, nor the princes of the earth shall ever cease to be. Anyone confirmed in this belief will not be disturbed by anything that may come to.”

An important tenet of Hinduism is to help those who are suffering. Daan is the original word in Sanskrit for donation meaning selfless giving. Daan ranks third among the list of 10 Niyamas (virtuous acts). Of all the things that are is possible to donate, to donate your own body is infinitely more worthwhile. The important issue for a Hindu is that which sustains life should be accepted and promoted as Dharma (righteous living) [37].

The Hindu faith perhaps represents less of a barrier to donation than cultural factors concerning family approval and death rituals. Hindu religion does not prohibit living or cadaveric donation to alleviate suffering. The use of body parts to benefit others is embedded in Hindi mythology [37]. The best known and widely worshipped deities in the Hindu pantheon is “Ganesha,” who is pictured with an elephant head and may represent the earliest depiction of xenotransplantation (Figure 8).

Figure 8.

The Hindu God, Ganesha.

8.6. Sikhism

Sikhism is a monotheistic religion. It was founded in 15th century in India by Guru Nanak Dev Ji (1469–1538). The word “Sikh” means learner [19]. There are no ordained priests in Sikhism. Gurdwara (the Sikh temple) (Figure 9) is in the care of a granthi (reader) who is appointed by the community. Sikhs think that faith is practiced by coping with life’s everyday problems. Sikhism stresses the importance of good deeds. Sikhs believe in life after death and a continuous rebirth. Sikhs are cremated and the physical body is not crucial to the cycle of rebirth. The soul is eternal and the body is just a flesh. Sikhism, as Hinduism, perhaps represents less of a barrier to donation than cultural factors concerning family approval and death rituals [38].

Figure 9.

The golden Gurdwara in Amritsar.

8.7. Confucianism

Confucianism is a Chinese philosophical tradition developed from the lessons of the Chinese philosopher Confucius (Kǒng Fūzǐ, 551–478 BC) (Figure 10). Confucianism is prevalent in the Mainland China, Taiwan, Hong Kong, Singapore, and Korea. The key principle in Confucianism is the Filial piety, which is the basis of Jen (humaneness). Children should be obedient to their parents when young, servant to them when they grow old, bury them after death, and worship them afterwards [39].

Figure 10.

Kǒng Fūzǐ.

The Confucian tradition assumes that one is born with a complete body and should end the same way as a form of filial piety. The body, hair, and skin are gifts from the parents and should not be damaged. This view will dictate that organ donation and transplantation are unfilial and disrespectful of parents. Therefore, Confucian beliefs could be considered as obstacles to organ donation [40].

Modern Confucian scholars have a different explanation. They stress on the words of Confucius who said, “The man of Jen is one who, desires to sustain himself, should sustain others”. They view that Jen and righteousness are more valued than preserving the integrity of the dead body and therefore approve donation for organ transplantation [41].

8.8. Shintoism

Shinto is the predominant faith in Japan (Figure 11). There is debate as to whether Shintoism can be classed as a religion. Shintoism is very much concerned with the idea of purity. Shinto believe that humans are born pure while that living make their bodies impure. The body after death is thus impure and hazardous, and interfering with dead body brings bad luck and might injure the relationship between the theitai (the bereaved person) and the dead person. In view of this belief, the concept of brain death does not go with the Shintoism view of death [42].

Figure 11.

Tori, a traditional Japanese gate at the Shinto shrine, symbolically marks the transition from the profane to the sacred.

Until 1997, legislations in Japan used to forbid deceased donation. In 1997, the law has been changed to allow transplantation from deceased donors. However, deceased donation is still not often carried out in Japan and the percentage of Japanese who have an organ donor card is among the lowest in the world [43].

8.9. Taoism

Taoism embraces a variety of philosophical traditions and religious beliefs in Eastern Asia. Tao roughly translates as “path” (of life). This faith dates since more than 2000 years. The Taoist philosophy emphasizes naturalness, non-action (wu-wei), and peace. Wu-wei dictates not taking action against the path of nature. Organ donation may be viewed according to this tradition as an attempt to change the natural process. Modern Taoist scholars have indicated that the body itself is only a shelter to the soul and attempts to change the body cannot truly affect the nature of life and approved organ donation for transplantation. They also cite Laotze when he stated that “Let what is superfluous to fill what is insufficient” [44] (Figure 12).

Figure 12.

Ying Yang, a Taoism symbol representing a visual depiction of the intertwined duality of all things in nature.

8.10. Gypsies

Gypsies have different ethnic groups without a formalized religion. They share common beliefs and tend to oppose organ donation and transplantation. This may be related to their beliefs about the afterlife. Their traditional belief is that for 1 year after death the soul retraces its steps. Therefore, the body should remain intact so as the soul can maintain its physical shape.

8.11. Bahá’í Faith

There is no opposition in the Bahá’í Faith against organ donation. It is an issue that is left to the person’s choice (Office of Public Information, Bahá’í International Community, November 10, 2005). The Bahá’í Faith assumes that organ donation is a noble act and insists on treating the donor’s body respectfully and burying the remains within 1 hour of travel time (from the hospital to the funeral place) [45].

9. Conclusions

The interplay of faith, religion, and wider cultural attitudes and their relationship with views on organ donation is so complex. Engaging faith leaders and providing them accurate, clear, and detailed information about the concepts of brain death, organ donation, and transplantation is of great importance.

Acknowledgments

Most of contents of this chapter could be viewed as a form of common knowledge. However, the authors acknowledge that it, expands the information originally presented in the article presented by. Oliver M, Woywodt A, Ahmed A, Saif I. Organ donation, transplantation and religion. Nephrology Dialysis Transplantation. 2011;26(2):437–444. DOI: 10.1093/ndt/gfq628.