CCAR RESPONSA

5763.3

Hastening the Death of a Potential Organ Donor

She'elah

I serve on the board of the Mid-America Transplant Association. One of our committees is struggling with the issue of non-beating organ retrieval. This concerns someone who may not be technically brain dead but cannot live without life support. All concerned recognize that the person will most likely die and the family has given consent for organ donation. The issue concerns the massive amount of anti-coagulant that must be given to keep the organ viable for donation. Technically, the administration of this medicine (usually heparin) "kills" the person because it causes internal bleeding. I know that we are supposed to do nothing to hasten death. I also know that there is nothing holier than saving a life by donating an organ. (Rabbi Susan Talve, St. Louis, MO)

Teshuvah

This question, as our sho'elet correctly notes, arises out of our commitment to two fundamentalBand, in this case, perhaps conflicting Jewish ethical principles. The first principle is what we might call the sanctity or the inviolability of human life.[1] We are forbidden to take any action that shortens human life or hastens death, even in the case of the goses, one whose death is imminent. The goses is compared to a flickering candle; "the one who touches it and causes it to go out is guilty of bloodshed."[2] At the same time, we are commanded to preserve human life through the practice of medicine (refu'ah),[3] and the transplantation of human organs has become a major weapon in our struggle against life-threatening diseases. The critical shortage of organs available for transplantation is in large part responsible for creating the situation to which our she'elah alludes.[4] Our task here is to consider whether the desire to acquire organs, in the name of the preservation of life, has led to the adoption of measures that are in some way destructive of life and of our duty to preserve it.

1. The Medical Context.[5] Human organs destined for transplant can be retrieved from one of four sources: cadavers; live donors; donors who are brain dead but whose organs are maintained by life-support technology; and non-heart beating donors (NHBDs), that is, individuals whose deaths are determined by cessation of heart and respiratory function rather than loss of whole brain function. Our she'elah deals primarily with donors in this latter category, which in some ways marks a return to the "old" cardiorespiratory criteria of death that were superseded by the general acceptance in the medical profession of neurological criteria (brain death) as the determinative indicator that death has taken place.[6] The NHBD category was reintroduced in response to two perceived needs. The first of these was the growing shortage of organs available to meet the demand for transplantation. The second was the desire among some dying patients, usually acting through their surrogates, to donate their organs upon death. To meet these needs, the University of Pittsburgh Medical Center developed a set of guidelines, commonly referred to as the "Pittsburgh protocol," to allow for "planned" organ retrieval. In the hypothetical case, a patient or the patient's surrogates make a legal and ethical decision to withdraw life support. The patient is weaned from the ventilator and is simultaneously prepared ("prepped") for organ retrieval. The patient's pulse is monitored by a femoral catheter, and the heart's electrical activity is measured by electrocardiogram (EKG). When these show a total absence of a pulse and of cardiac activity for a period of two minutes, the patient is pronounced dead and organ retrieval may proceed. If the patient spontaneously resumes breathing after the removal of the ventilator, he or she is returned to the intensive care unit.

During this process, anticoagulant drugs such as heparin are administered to the donor a few minutes before the withdrawal of life support. This is done to prevent blood clots that would render the retrieved organs useless for transplantation. Our she'elah indicates that heparin "'kills' the person because it causes internal bleeding." This assertion, as far as we can determine, is unproven. According to a report by the Institute of Medicine, an arm of the National Academy of Science, heparin may cause internal bleeding if administered to some NHBDs, especially in large doses. The report therefore concludes that it is appropriate to use heparin for the purposes described here, provided that this decision is made on a case-by-case basis and that the drug is administered carefully, so as not to harm the patient or to hasten his or her death.[7] According to the information made available to us, standard medical practice restricts the dosage of heparin administered to NHBDs to the "safe" range, so that it does not harm the donor. Indeed, given that hemorrhagic organs would be useless for transplantation, physicians have no motivation for administering these drugs in doses large enough to kill the patient by causing internal bleeding.[8] In light of these findings, there is no Jewish ethical reason to prohibit the use of heparin or other anticoagulants in this situation, provided that the drugs are in fact administered so as not to shorten the life of the donor.

2. Non-Heart Beating Donors and The Criteria for Death. Beyond the specific concern of anticoagulant drugs, our she'elah raises a more general and troubling issue. The "Pittsburgh protocol" specifies that organs may be retrieved once Athe patient meets the cardiopulmonary criteria for death, i.e., the irreversible cessation of cardiopulmonary function,"[9] and it determines that "irreversible cessation" has occurred once the patient's pulse has stopped for a period of two minutes. To wait longer than two minutes would subject the internal organs to warm ischemia (damage caused by lack of blood flow) and possibly render them useless for transplantation. This presents a serious problem for those who accept neurological criteria (brain death) as the determinative indicator of death. Put starkly, "there are no clear empirical data proving that a patient who meets the Pittsburgh protocol's criteria for cardiopulmonary death, two minutes of pulselessness, also meets the neurological criteria for death, irreversible loss of all brain functions."[10] Indeed, since "no one would claim that two minutes of anoxia is sufficient evidence that the brain has ceased to function,"[11] a patient declared dead according to the Pittsburgh protocol may not in fact be brain dead at the time his or her organs are retrieved. We must therefore address the question: are the Pittsburgh protocol's criteria for death for non-heart beating organ donors acceptable according to our understanding of Jewish tradition?

The "classic" halakhic "definition" of death (that is, the set of criteria accepted by virtually all Jewish legal authorities prior to the late 1960s) is based upon cardiopulmonary indicators: death is established by the complete and irretrievable cessation of heartbeat and respiration.[12] This standard proceeds from Mishnah Yoma 8:6-7, which declares that the saving of life supersedes the laws of Shabbat even when it is not certain that an individual's life is in danger or, for that matter, that he is still alive.[13] Thus, when a building collapses upon an individual on the Sabbath, the halakhah permits all necessary labor to remove the debris so that it can be determined whether he is still alive. The Talmud (BT Yoma 85a) cites a dispute as to how we are to ascertain that fact: do we examine his heartbeat or his respiration? The major codes rule that the cessation of respiration is the determinative criterion for death.[14] This does not mean that heartbeat is an irrelevant factor; later poskim realized that the cardiac and respiratory functions are inextricably linked.[15] Thus, R. Moshe Sofer, the "Chatam Sofer" (18th-19th century Hungary), established a threefold set of criteria for death: "when a person lies still as a stone [i.e., absence of reflexes], with no discernible pulse, and then his respiration ceases, he is certainly dead."[16]

Yet alongside the Yoma passage, we find in the halakhic sources suggestions of a different "definition," namely that death is indicated by the cessation of neurological activity.[17] With the advent of the "Harvard criteria,"[18] which established testing protocols for determining that all neurological activity (including that of the brain stem) has ceased, some halakhists came to accept brain death as a proper indication of death according to Jewish law. This does not, in their view, contradict the cardiopulmonary standard as promulgated by Sofer: death is still indicated by the complete cessation of independent cardiac and respiratory activity. The difference is one of diagnostic technology. In Sofer's day, death could be determined solely by the actual measurement of heartbeat and respiration. Today, when the accepted tests can establish the cessation of all neurological activity, the patient may be declared dead, since "brain death is final and irreversible and there is no possibility that autonomous respiration will begin anew."[19] The fact that the organs of a brain-dead person are kept functioning by means of life support technology does not mean that the person is still alive, because with the cessation of neurological activity autonomous, independent heartbeat and respiration cannot be restored. Those Orthodox poskim who accept brain death as an adequate indicator of death have ruled in favor of heart and liver transplantation surgery, which require that these organs be retrieved from brain-dead donors.[20] This stance, however, remains controversial within the Orthodox world; most noted halakhists continue to insist on the literal application of the "Chatam Sofer" standard: death occurs only when heartbeat and respiration have irretrievably ceased.[21]

Liberal halakhic opinion,[22] including that of this Committee,[23] accepts the brain death standard as a proper criterion for death. Brain death, again, does not replace the "older," cardiopulmonary criteria; rather, it confirms them. Since the determination of brain death signals that the body has irretrievably lost its ability to maintain cardiopulmonary functions on an independent basis, the brain death standard satisfies the demands of both Jewish tradition and simple moral sense. When clinical tests establish beyond scientific doubt that brain activity has irretrievably ceased and that circulation and respiration are maintained solely through mechanical means, the patient is dead. It is then, and only then, that the body's organs may be removed for transplantation.

As we have seen, the Pittsburgh protocol standard does not meet the criteria for brain death. We should also note that it does not meet the Jewish standard of establishing death according to cardiopulmonary criteria. That standard, like the brain death standard, was meant to indicate that heartbeat and respiration have irreversibly ceased to function. Two minutes of pulselessness are not sufficient to meet this test: cardiopulmonary functions can return spontaneously or be restored through resuscitation during a much longer period, even up to ten minutes following asystole (cardiac arrest).[24] It may be, of course, that physicians and family members have no intention of resuscitating such a patient. That decision can be a proper one. As we have written, there are times when it is ethically permissible to withdraw most forms of medical treatment, to "allow nature to take its course" and to let the patient die without further "heroic" measures.[25] Yet such a decision does not indicate "irreversibility." The fact that pulse and respiration will not be restored through medical intervention does not prove that they cannot be restored. Until that latter point is reached, until it is clear that "there is no possibility that autonomous respiration will begin anew," we cannot certify that the cessation of heartbeat and respiration are in fact irreversible. It is for this reason that the brain death standard, which does testify to the irreversible cessation of autonomous heart and lung activity, meets the criteria for death as set forth in the sources of our Jewish tradition.

3. To Change the Criteria for Death? Why have some hospitals and clinics adopted the Pittsburgh protocol as a standard for determining the death of non-heart beating organ donors? Why have they abandoned the brain death standard, which is still recognized as the predominant criterion for establishing death?[26] The obvious, practical reason is the desire to increase the availability of organs for transplantation: "(T)he number of persons eligible to donate organs who die when heart and lung functions stop is believed to be much larger than the number who are pronounced 'brain dead' while on life support."[27] This desire, to be sure, is not evidence of evil intent. The goal of organ transplantation, after all, is to save human life, to fulfill the mitzvah of pikuach nefesh. The donors (or their surrogates) have consented in advance to this procedure: they have asked to be removed from life support and have permitted the removal of the needed organs from their bodies. Nor is the acceptance of the Pittsburgh protocol necessarily an act of cynical manipulation, the altering of the definition of death in order to serve our own purposes, however exalted. As some ethicists argue,[28] "death" is not a biological event that can be defined by medical criteria. All that science can do is to identify specific clinical situations, such as the irreversible cessation of heartbeat or of brain activity. The decision to regard those situations as evidence of "death" is a legal or moral decision, arrived at through discussion among scientists, practitioners, and the community as a whole. Death "happens," in other words, at a point in the clinical situation that is morally, sociologically, and anthropologically acceptable. Why then is it wrong or immoral to declare death at a moment which is consistent with the retrieval of vital organs? Such thinking may have motivated the acceptance of the brain death standard several decades ago,[29] and such thinking lies behind the Pittsburgh protocol and other current proposals to accept alternative criteria for death (for example, higher-brain death or a diagnosis of permanent vegetative state) so as to increase the availability of organs for transplantation.[30]

With all this in mind, should we Reform Jews, who honor our Jewish tradition but who are open to new ways of thinking about our moral responsibilities, reconsider our own criteria for death? Should we abandon the traditional Jewish standards in favor of a new definition that, like the Pittsburgh protocol, would facilitate the retrieval of more human organs for transplantation?

We oppose such a step. We do so out of our commitment to the principle with which we began this teshuvah: the sanctity of human life. Any discussion of a Jewish approach to the determination of death must proceed from that fundamental affirmation. To perceive human life as "sacred," in Jewish terms, is to hold it inviolate: as the ultimate possession of the God who has created it and given it to us, human life may never be taken or shortened save for those circumstances under which the Torah permits or mandates that outcome.[31] For this reason, although we are not obligated to delay a terminal patient's impending death through the employment of therapeutically useless measures, we are forbidden to practice active euthanasia or assisted suicide, to hasten the death of that patient. The fact that there is nothing physicians can do to save the life of this patient does not entitle us to kill him or her, even out of compassion and Bimportantly for our she'elahBeven when it would benefit others were we to do so.[32] It makes no difference that the patients or their surrogates have consented to them. The sanctity of life precludes suicide just as it forbids homicide.[33] The act, however benign or beneficent, remains an act of killing.

Since our tradition regards human life as sacred, it bids us to do everything we can to save life and to heal the sick. By that same token, however, because all human lives are equally sacred, it does not and cannot permit us to save the life of one person by shortening the life of another.[34] Yes, we have accepted "new criteria for death (the brain-death standard) that justify the retrieval of human organs from donors whose hearts are still beating. Yet as we have written, the neurological criteria did not represent a change but rather a reliable alternative indicator that the traditional Jewish standard for death (the complete and irreversible cessation of autonomous heartbeat and respiration) had been met. A brain dead person is, by Jewish criteria, dead. By contrast, a medical institution that implements the Pittsburgh protocol or some of the other "alternative" criteria for death is retrieving organs from persons who, in the eyes of Jewish tradition, are likely still alive. That is a difference that makes all the difference in the world. The prospect of killing NHBDs may not trouble those who do not share the Jewish conception of the sanctity of human life. But those of us who do, who participate in a tradition that regards human life as inviolate and beyond our power to destroy even for beneficial purposes, find it a chilling thought indeed.

Conclusion. The administration of anticoagulant drugs to a non-heart beating organ donor is permissible so long as it is done so as not to harm the patient or hasten his or her death. Organ retrieval is permissible when, but not before, the patient is declared to be brain dead.

NOTES

  1. The term "sanctity of human life" is not native to the Jewish tradition. We do not find its probable Hebrew equivalent, kedushat hachayim, in the Talmudic or halakhic sources. On the other hand, it reflects the conviction, most certainly present throughout Jewish thought and discussed below in this responsum, that human life possesses supreme value and is therefore inviolate. This insight is applied in contemporary halakhic writing to the issue of suicide: (R. Ovadyah Yosef, Resp. Yabi`a Omer 8, Orach Chayim 37, sec. 5). And, in fact, some present-day Orthodox writers do use the term kedushat hachayim or "sanctity of life" as a way of expressing this commitment: see Piskey Din Rabani'im 1, p. 164, and J. David Bleich in Fred Rosner and J. David Bleich, eds., Jewish Bioethics (Brooklyn: Hebrew Publishing Co., 1985), 273. We think, therefore, that the term "sanctity" conveys an accurate description of the Jewish belief that life possesses inestimable value and must be protected as though it belongs to the God Who created it.
  2. Semachot 1:1: "the goses is considered a living person in all respects"; Rambam, Yad, Avel 4:5; Shulchan Arukh Yore De`ah 339:1.
  3. For sources and discussion, see our responsa 5754.14, "Treatment of the Terminally Ill," Teshuvot for the Nineties (TFN), 337-363, at pp. 346ff. (http://www.ccarnet.org/cgi-bin/respdisp.pl?file=14&year=5754); 5754.18, "Physicians and Indigent Patients," TFN, 373-380, at pp. 373-375 (http://www.ccarnet.org/cgi-bin/respdisp.pl?file=18&year=5754 ); and 5761.7, "Human Stem Cell Research," at notes 5-13 (http://www.ccarnet.org/cgi-bin/respdisp.pl?file=7&year=5761 ).
  4. See, in general, our responsum 5763.2, "Live Liver Donation."
  5. We are deeply indebted to the Bioethics Committee of the Union of American Hebrew Congregations, chaired by Harvey L. Gordon, M.D., for their assistance and instruction in the preparation of this part of our teshuvah.
  6. "Brain death" refers to the complete and irreversible cessation or stopping of all cerebral and brain-stem function. The clinical tests to determine brain death are described in AA Definition of Irreversible Coma - Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, Journal of the American Medical Association 205 (1968), 337-340. That brain death became a consensus standard is indicated by the statement signed by nearly all the leading American authorities in the field in Journal of the American Medical Association 246 (1981), 2184-2187. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research officially recognized the brain death standard in Defining Death: A Report on the Medical, Legal, and Ethical Issues in the Determination of Death (Washington: US Government Printing Office, 1981). On the question of brain death in Jewish law and in the Reform responsa tradition, see below in this teshuvah.
  7. Institute of Medicine, Non-heart-beating Organ Transplantation: Medical and Ethical issues in Procurement (Washington: National Academy Press, 1997); see especially pp. 4 and 52.
  8. George J. Agich, "From Pittsburgh to Cleveland: NHBD Controversies and Bioethics," Cambridge Quarterly of Healthcare Ethics 8 (1999), 517-523. In the interests of full disclosure, we note that Dr. Agich is the chair of the Department of Bioethics at the Cleveland Clinic Foundation. The Cleveland Clinic was the subject of a controversy in 1997 over the very issue that impels this she'elah: the administration of anticoagulant drugs to non-heart beating donors prior to the withdrawal of life support. Agich supports the procedure on the grounds indicated here, namely that the drugs are administered under the Institute of Medicine guidelines (see preceding note) and in dosages that do not cause harm to the patient. The Bioethics Committee of the UAHC, in a communication to this committee, agrees with Agich's assessment: "(we) have found nothing in the literature to substantiate the assumption of your questioner that heparin causes internal bleeding, much less that it is the cause of the donor's death."
  9. University of Pittsburgh Medical Center, "Management of Terminally Ill Patients Who May Become Organ Donors After Death," 1992. A text of the protocol is included in Robert M. Arnold, et al., Procuring Organs for Transplant: The Debate Over Non-Heart-Beating Cadaver Protocols (Baltimore: The Johns Hopkins University Press, 1995), 235-249. The quotation in the text is at p. 240, paragraph S. See also Kennedy Institute of Ethics Journal (1993), 3:A-1 to A-15. The "the cardiopulmonary criteria for death" referred to in the protocol match those set by the Uniform Declaration of Death Act (UDDA), sec. 1, 12 ULA 340 (suppl. 1991): "An individual who has sustained either irreversible cessation of circulatory and respiratory functions, or irrersible cessation of all functions of the entire brain, including the brain stem, is dead."
  10. Arnold, et al. (note 9, above), 7.
  11. Joanne Lynn, "Are the Patients Who Become Organ Donors under the Pittsburgh Protocol for 'Non-Heart-Beating Donors' Really Dead?" in Arnold et al. (note 9, above), 91-102. The quotation is at 99. Dr. Lynn is director of the Center to Improve Care of the Dying at George Washington University. At the time of the publication of the Arnold volume, she was a Professor of Medicine at Dartmouth-Hitchcock Medical Center in Hanover, NH.
  12. See, in general, the article by our colleague, Moshe Zemer, "Terumat Eivarim Vehahalakhah," in R. Cohen-Almagor, Dilemot Be'etikah Refu'it (Jerusalem: Van Leer Institute, 2002, 265-282.
  13. In Jewish tradition, the saving of life is called pikuach nefesh. The situation referred to in our Mishnah is one of safek nefashot, a case where it is uncertain that life is in fact in danger. On this subject, see our responsum 5763.2, "Live Liver Donation."
  14. See Yad, Shabbat 2:19 and Shulchan Arukh Orach Chayim 329:4. The ruling is based upon the statement of Rav Papa in BT Yoma 85a, along with the citation in that passage of Genesis 7:22 ("every creature with the breath of life in its nostrils").
  15. That is to say, the poskim have rejected the literal reading of Rambam and the Shulchan Arukh, according to which cessation of respiration is the exclusive indicator of death. The 19th-century Galician authority Rabbi Shalom Schwadron, for example, declared that cessation of breathing indicates death only "if there is no indication to the contrary...but if any sign of vitality is detected elsewhere in the body...then it is obvious that we do not declare death on the basis of the cessation of respiration alone" (Resp. Maharsham 6:91). See also R. Isser Yehudah Unterman in No`am 13 (1970), 1-9, and R. Eliezer Yehudah Waldenberg, Resp. Tzitz Eliezer 9:46 and 10:25, ch. 4.
  16. Resp. Chatam Sofer, Yore De`ah, no. 338.
  17. These include the following: 1) M. Ohalot 1:6: one whose head is severed from the body is immediately regarded as dead and capable of transmitting ritual impurity, even if all physical reflexes have not yet ceased (and see Rambam's commentary to that mishnah, where he speaks of an "animating force" in the body that emanates from one source, suggesting that he saw the brain as the source of all bodily reflexes, including respiration); 2) BT Chulin 21a: a person whose neck is broken immediately transmits ritual impurity (i.e., is dead); 3) Yad, Tumat Met 1:15, codifying the above sources: "one does not transmit impurity until the soul has departed... if the neck has been broken... or if the head is severed... he transmits impurity even though there may be some residual reflexes in one of his limbs."
  18. See note 6, above.
  19. Dr. Avraham Steinberg, "The Definition of Death," in Fred Rosner, ed., Medicine and Jewish Law (Northvale, NJ: Jason Aronson, 1990), 146. Steinberg's definition of brain death parallels that of the President's Commission (note 6, above): "The heart and lungs are not important as basic prerequisites to continue life but rather because the irreversible cessation of their functions shows that the brain had ceased functioning." The "accepted tests" he lists are: apnea tests, cerebral blood flow studies (e.g., radioisotope studies), Doppler tests, cerebral arteriograms, and electrophysiological examinations. "The electroencephalogram is insufficient to determine total brain death"; loc. cit.
  20. See especially R. Moshe David Tendler, who is both a rosh yeshivah at RIETS seminary and the chair of the biology department at Yeshiva University, "Kevi`at rega` hmavet ve-hashtalat eivarim," in A. Steinberg, ed., Emek Halakhah (New York: yeshiva University, 1989), 213-219 ("that the heart continues to beat (after brain death) is no sign of life, since the heart, when removed from the body and placed in a bucket with certain chemicals can maintain its pulse for hours or even for weeks"; p. 215); decision of the Chief Rabbinate of Israel, "Hashtalat lev be-yisra'el," published in Techumin 7 (1986), 187-189; R. Shelomo Goren, Torat harefu'ah (Jerusalem: Hemed, 2001), 82 and 112; R. Moshe Feinstein, Resp. Igerot Moshe, Yore De`ah 3:132 (dated 1976) and Choshen Mishpat 2:72 (dated 1978). The position of Rabbi Feinstein on this issue remains a subject of controversy in Orthodox circles, largely because earlier teshuvot of his explicitly forbade the heart transplantation procedure. Tendler, op. cit., who is Feinstein's son-in-law, insists that Feinstein changed his view as he became more informed of the technology that measures brain death.
  21. Among these are R. Eliezer Yehudah Waldenberg, Resp. Tzitz Eliezer 10:25, ch. 25; R. Yitzchak Ya`akov Weiss, Resp. Minchat Yitzchak 5:7, 9; and R. S. Z. Auerbach, cited in Nishmat Avraham, vol. 5, Yore De`ah 339:1. See, in general, J. David Bleich, Contemporary Halakhic Problems, v. 4 (New York: Ktav/Yeshiva, 1995), 316-350.
  22. See the responsa of R. Avram Reisner and R. Elliot N. Dorff in Proceedings of the Committee on Jewish Law and Standards, 1986-1990 (New York: The Rabbinical Assembly, 2001), 13-126.
  23. Contemporary American Reform Responsa (CARR), no. 78 (http://www.ccarnet.org/cgi-bin/respdisp.pl?file=78&year=carr ); R. Walter Jacob, Questions and Reform Jewish Answers (QRJA), no. 156 (http://www.ccarnet.org/cgi-bin/respdisp.pl?file=156&year=narr ).
  24. See N. Zamparetti et al., "Defining Death in Non-Heart Beating Donors," Journal of Medical Ethics 29 (2003), 182-185, at notes 19-24.
  25. On this subject, see our responsum 5754.14, "Treatment of the Terminally Ill," TFN, 337-363 (http://www.ccarnet.org/cgi-bin/respdisp.pl?file=14&year=5754) .
  26. The Bioethics Committee of the UAHC informs us that the institutions employing the Pittsburgh protocol constitute "a small percentage" of all medical establishments and that "brain-dead donors continue to constitute the vast majority."
  27. Arthur L. Caplan, in Arnold, et al. (note 9, above), 208. Dr. Caplan is director of the Center for Bioethics at the University of Pennsylvania.
  28. On the following, see Zampretti et al. (note 24, above).
  29. Henry Beecher, the chairman of the Harvard committee that established the brain death criteria (see note 6, above), wrote in 1971: "At whatever level we choose to call death, it is an arbitrary decision... The need is to choose an irreversible state where the brain no longer functions. It is best to choose a level where, although the brain is dead, usefulness of other organs is still present"; cited in Zampretti et al. (note 24, above) at note 36.
  30. Among these are James M. DuBois, "Non-Heart-Beating Organ Donation: A Defense of the Required Determination of Death," Journal of Law, Medicine and Ethics 27 (1999), 126-136; Robert D. Truog, "Is It Time to Abandon Brain Death?" Hastings Center Report 27:1 (1997), 29-37; Arnold, R. M. and Youngner, S. J., "The Dead-Donor Rule: Should We Stretch It, Bend It or Abandon It?" Kennedy Institute of Ethics Journal 3 (1993), 263-278; Zampretti et al., note 24, above; and Linda Emanuel, "Reexamining Death: The Asymptomatic Model and a Bounded Zone Definition," Hastings Center Report 25:4 (1995), 27-35. The "permanent vegetative state" criterion is a feature of Emanuel's proposal.
  31. One major expression of this commitment is the notion that one's life is not one's personal property, to dispose of as one wishes; rather, human life belongs to God, to Whom we are obliged to render an account for the way in which we have used it. Thus, writes Maimonides, the beit din is not permitted to accept a ransom from a murderer in order to spare him from execution, "for the life of the victim is not the property of the avenger (or of the court) but of the Holy One" (Yad, Rotzeach 1:4). In a similar vein, under Jewish law we cannot execute a wrongdoer on the evidence of his own confession. The reason for this, explains one scholar, is that "the life of the human being is not his own property but the property of God, Who said 'all lives are mine' (Ezekiel 18:4). Therefore, a person's own confession has no power to dispose of that which does not belong to him" (Commentary of R. David ibn Zimra to Yad, Sanhedrin 18:6).
  32. See TFN, no. 5754.14, 337-363, "On the Treatment of the Terminally Ill" (http://www.ccarnet.org/cgi-bin/respdisp.pl?file=14&year=5754) .
  33. Jewish law forbids suicide as it forbids homicide; Semachot 2:1; BT Bava Kama 91b (and see Genesis 9:5 and Rashi ad loc.); Shulchan Arukh Yore De`ah 345. The halakhah as developed in the later sources presumes that the one who takes his own life is driven to do so by circumstances beyond his or her control; in other words, suicide by definition is an irrational act.
  34. See BT Sanhedrin 74a, Rabbah's classic question mai chazit: "How can you say that your blood is redder than that of another? Perhaps his blood is redder than yours."

If needed, please consult Abbreviations used in CCAR Responsa.