Clarifying the recent controversy about organ donation after cardiac death

 
The US House started an investigative hearing this week following two recent New York Times articles alleging cases in which U.S. hospitals, particularly rural ones, erred in protocols for declaring cardiac death before organ donation. The allegations are upsetting. They demand clarification and rectification to preserve public trust in the organ donation system.

Critically, these reports did not address organ donation after brain‑stem death, the topic long debated in halachic discourse. Supporters of halachic organ donation after brain‑stem death can maintain their general support for this life‑saving practice. Here’s why:

There are two distinct forms of posthumous organ donation: Donation after Brain Death (DBD), about which there’s an extensive discussion regarding whether halacha accepts this criterion for death; and Donation after Cardiac (or Circulatory) Death (DCD), the more recent practice highlighted in the articles and not supported in halachic circles.

1. Donation after Brain Death (DBD). DBD occurs after a person, entirely unresponsive to their environment, has been rigorously tested for irreversible cessation of spontaneous respiration. When done according to protocol, the tests show that they can never “wake up” in any sense nor ever breathe on their own. In halachic circles, we term this “respiratory brain death,” since neurological criteria test the brain‑stem area governing autonomous breathing.

The tests are sophisticated and rigorous. Once a patient is properly shown to meet this criterion, he or she is dead under criteria set by global medical associations, the Israeli Chief Rabbinate, and many (but not all) poskim. A ventilator preserves the organs by supplying oxygen to the bloodstream. At this point, organs may be retrieved to give life to patients who would otherwise die. Crucially, before any actions are taken to facilitate donation, death must already have been confirmed.

2. Donation after Cardiac (or Circulatory) Death (DCD). DCD occurs after death is declared due to irreversible cessation of heart function. Ordinarily, once the heart stops, organs soon lose viability because they have no oxygen supply. In DCD protocols, conversations begin while the patient is still alive, but the healthcare team and the family has (a) concluded that further intervention is inappropriate and (b) the decision is made to withdraw support (e.g., ventilator) that will lead to cardiac arrest. This decision to withdraw medical treatments is made either through advance directive (e.g. a “living will”) or by the healthcare proxy.  

If the patient is a registered organ donor, or the proxy agrees to donate, then withdrawal proceeds in an orchestrated process allowing the heart to stop, death to be declared, and organs retrieved. Because this is a controlled process, it is termed ‘controlled DCD’ (cDCD). In many jurisdictions, cDCD supplies a quarter to a half of annual donated organs.

The New York Times articles focused exclusively on lapses in DCD protocols, not on brain‑stem death. 

Israel does not perform cDCD, which is rarely discussed in halachic literature because it involves actively withdrawing life support (palliative extubation, “pulling the plug”) that causes imminent death, an action almost universally forbidden by Orthodox halachic authorities. 

How do we ensure a patient meets respiratory brain‑death criteria before permitting halachic organ donation?

Regarding DBD, Ematai supports the Israeli statutory tests developed by the Israeli Medical Association and the Chief Rabbinate alongside Rabbi Prof. Avraham Steinberg, a neurologist and member of Ematai’s rabbinic advisory board. In brief, these thorough requirements include:

• An adequate interval (e.g., 48–72 hours) after the initial catastrophic event so the cause and irreversibility of damage are clear.
• A comprehensive bedside exam by two trained doctors confirming total unresponsiveness to painful stimuli and absence of brain‑stem reflexes. (Patients in a persistent vegetative state, by contrast, display some reflexes.)
• An apnea test confirming absence of spontaneous respiration.
• A confirmatory imaging study demonstrating absence of cerebral blood flow, indicating irreversible brain‑stem damage.

At that point the patient is declared dead. Organ retrieval can then allow the deceased to bestow the gift of life before burial.

These exams are common in the United States, though states and hospitals may vary in details. They are routinely performed at major centers and may be requested by a family under our guidance. Ematai strongly recommends halachic consultation before declaring death under brain‑death criteria to reassure families that all appropriate steps were taken.

Very rarely, media reports, some unconfirmed, describe inexperienced providers not following their DBD protocols, particularly in hospitals with limited exposure to such cases. These errors are avoidable by adhering to the strict standards above. In fact, Israel does not have such allegations because of consistent national protocols.

Unfortunately, careless mistakes occur in many sensitive medical settings when protocols are ignored. Recent high‑profile fertility clinic mishaps illustrate this, yet couples still pursue IVF while insisting on rigorous safeguards. Likewise, those who halachically accept respiratory brain‑death criteria should feel assured that proper tests confirm death. Robust oversight, transparency, and communal education allows for responsible, life‑affirming action for countless patients.

Seventeen to twenty people die every day in America alone while awaiting an organ transplant. Many of us know people who have died on a waiting list. Any of us might one day need a life‑saving organ. We must therefore improve systems so we or our loved ones do not die needlessly because mistrust led usable organs to decompose in the ground.

To learn more about halachic organ donation and Ematai’s Option 18 education initiative, please visit option18.org.