Living Organ Donation in Halakha

An essay from Havineini – a collection of essays written by the Morot L’Halakha | Cheshvan 5779
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Introduction

In 1818 the first human–to–human blood transfusion was recorded when the life of a woman who hemorrhaged after giving birth was saved. The first live organ donation occurred in 1954. These modern medical miracles and the many that followed have saved numerous lives.

Judaism places a high value on human life. The Mishna in Sanhedrin 4:5 teaches us that ‘one who saves one life, it is as though he has saved an entire world.’ The Torah in Vayikra 19:16 commands us לא תעמוד על דם רעך – ‘Do not stand idly by your neighbor’s blood.’ The Biblical commentaries and the Talmud debate the extent and the application of this commandment. Modern poskim have been challenged to reinterpret the scope of this commandment in the changing times of medical innovation. The development of Halakhic writing on the topic of organ donation is a good example of the interaction between Halakha and modern medicine. This article will explore whether one is halakhically permitted to donate tissues and organs, and whether there are occasions when one is required to do so.

Background

As the transplant gap (the gap between the number of people who need transplants and the number of donations available) widens, new organ sources are being sought. Live donations have three benefits – they are more readily available, the donation time can be chosen, and they are generally more effective. Today common live donations include kidney, lung, pancreas, liver, skin, bone marrow, and blood. In order to discuss the halakhic ramifications of donation, it is important to know how donation effects the donor and to differentiate between different types of donations.

In a live kidney donation, the donor donates one of two healthy kidneys. According to many studies, having one kidney should not have a significant impact on the donor’s life. For living kidney donors, the remaining kidney will enlarge slightly to do the work that two healthy kidneys share, but the donor will never have the “back–up” that a normal person has in the case of injury or illness in the other kidney.^[1]

In a live lung donation, a lobe of one of the lungs is given. There will be some reduction in lung capacity for the donor. Often two live donors are used, each donating one lobe to create two “lungs” for the recipient. Partial pancreas and intestine donations are similarly possible. Lungs, intestines and pancreas do not regenerate, but donors usually have no significant problems with the reduced function.

In a live liver donation, a part of the donor’s liver is removed and placed in the recipient. The remaining part of the donor’s liver is sufficient to maintain normal body functions. The recipient also receives a large enough segment of the donor liver to maintain body functions. During approximately the next two months, the remaining and transplanted parts of the donor liver grow to normal size, providing normal long–term liver function for the donor and the recipient. This is generally more effective than a liver from a deceased donor.

Bone marrow transplant has undergone some changes in recent years. Today, bone marrow transplantation (BMT) is only one of two methods of collecting blood–forming cells for bone marrow transplants. Doctors use needles to withdraw bone marrow from both sides of the back of the pelvic bone. This is done under anesthesia. Bone marrow regenerates within a few weeks. Another, less invasive, method is peripheral blood stem cell transplantation. PBSCT is a process in which stem cells are obtained through apheresis (blood filtration). The donor is given a medication to increase the number of stem cells released into the bloodstream for a few days before apheresis. The blood is then removed, filtered for stem cells and returned to the body. The process takes a few hours and is similar to other blood product donations such as platelet donation. Apheresis usually causes minimal discomfort. Unlike bone marrow donation, PBSC donation does not require anesthesia. The medication that is given to stimulate the release of stem cells from the marrow into the bloodstream may cause some side effects, but these generally end within 2 to 3 days of the last dose of the medication. Regeneration of bone marrow or stem cells takes about three weeks.

Blood donations and blood component donations incur practically no risk and minimal discomfort. Blood is regenerated within 4 to 6 weeks.

Is Donation Permissible?

Much has been written about halakha and live organ donation. In the early years of transplant surgery the discussion tended to be about whether one was permitted (mutar) to donate, considering the risk factors involved in the donation process, or whether the risk too great, rendering a donation forbidden (assur). Must one come to harm to save the life of another? May one put oneself in danger to save another? Must one preserve their own health at the risk of the life of another? These questions and others are relevant to the question of live organ donation.

There is a Talmudic discussion in Bava Metzia 62a about the verse וחי אחיך עמך – ‘and let your brother live with you.’ The Talmud cites a well–known baraita about two people who are walking through the desert. One is in possession of enough water to get one person to civilization, but drinking it will leave the other to die. If they share the water, both will die. The Tanna Ben Petura explains that according to the verse it is better for them both to drink and die, rather than to see one friend die at the other’s expense. The Talmud tells us that this was the halakhah until Rabbi Akiva read the verse differently, inferring from the word  עמך– with you –that the obligation to keep your brother alive is only if you too are with him. If you will die as well, you have no obligation to keep him alive, because your life precedes your friend’s life. Therefore, R Akiva ruled that the one in possession of the canteen of water should save himself.

תלמוד בבלי מסכת בבא מציעא דף סב עמוד א

ורבי יוחנן, האי וחי אחיך עמך מאי עביד ליה? – מבעי ליה לכדתניא: שנים שהיו מהלכין בדרך, וביד אחד מהן קיתון של מים, אם שותין שניהם – מתים, ואם שותה אחד מהן – מגיע לישוב. דרש בן פטורא: מוטב שישתו שניהם וימותו, ואל יראה אחד מהם במיתתו של חבירו. עד שבא רבי עקיבא ולימד: וחי אחיך עמך – חייך קודמים לחיי חבירך.

On the other hand, the Talmud in Sanhedrin 74a rules that one must sacrifice one’s life rather than commit murder. It explains that this is a logical deduction and brings a story in which Rabbah tells a man that he must allow himself to be killed instead of killing another. Rabbah explains his reasoning: “for who says that your blood is redder than that of your victim? Perhaps the blood of that man is redder than yours!” Since we cannot objectively know whose life is more valuable, it is forbidden to take one life in order to save another.

תלמוד בבלי מסכת סנהדרין דף עד עמוד א

רוצח גופיה מנא לן? סברא הוא. דההוא דאתא לקמיה דרבה ואמר ליה אמר לי מרי דוראי זיל קטליה לפלניא ואי לא קטלינא לך אמר ליה לקטלוך ולא תיקטול מי יימר דדמא דידך סומק טפי דילמא דמא דהוא גברא סומק טפי!

These two examples are extremes. In the first, a person must actively save himself before his friend as he is in possession of the water. In the other he must let himself be killed rather than actively murder the other person. What do we do with the gray–area situations in between?

Organ donation presents us with these types of scenarios. There is a range of situations in which an organ donation would be required. Some are clearly life or death situations for the person receiving the donation, while others, such as corneal and uterine transplants, are not. In some cases, it is a question of quality of life. Living on dialysis is difficult and inconvenient. A kidney transplant will end the days of being tied to the hospital. There is also a difference in the effect on a donor between organs which regenerate (e.g. blood and bone marrow) and those which do not (e.g. kidneys). The long term risk to the donor must be considered.

The basis for seeing organ donation as a mitzvah may be found in a verse in Vayikra 19:16 – לא תעמד על דם רעך – ‘Do not stand idly by your neighbor’s blood.’ An example of this concept is given in Sanhedrin 73: ‘From where do we know that if one sees another drowning in a river or a wild beast or robbers attacking him that he is obligated to save the other person? From the verse of לא תעמד על דם רעך – you must save him from death.’ The Talmud asks if indeed we learn this from the verse in Vayikra or alternatively is the idea derived from the laws of returning lost items (“והשבתו לו – And you shall return it to him,” Devarim 22:2)? The Talmud explains that we need both verses, one to teach us that we are required to save the person’s life, and the other to teach us that we are required to expend money to hire someone to rescue the other. From here we see that we are obligated to save a person in need through both physical and financial means.

תלמוד בבלי מסכת סנהדרין דף עג

מנין לרואה את חברו שהוא טובע בנהר או חיה גוררתו או לסטין באין עליו שהוא חייב להצילו? תלמוד לומר לא תעמד על דם רעך. והא מהכא נפקא? מהתם נפקא: אבדת גופו מניין – תלמוד לומר והשבתו לו! – אי מהתם הוה אמינא: הני מילי – בנפשיה, אבל מיטרח ומיגר אגורי – אימא לא, קא משמע לן.

The Talmud Bavli does not discuss the requirement when the attempt at saving the other requires one to endanger oneself. Despite the fact that the cases enumerated in the Talmud seem to be dangerous ones, the Rishonim on the Talmud in Sanhedrin overwhelmingly read this source as indicating that one is not obligated to risk one’s life in order to save another.

In the Talmud Yerushalmi in Terumot 8:4 47a R Imi finds himself in a very dangerous situation as a captive. The rabbis discussed what to do. R Yonatan said he should be wrapped in shrouds, meaning that he should be abandoned, leaving him in captivity where he would surely die. R Shimon Ben Lakish chose to save him, saying “either I kill (the captors) or be killed, I will go and save him by force,” thus knowingly risking his life to save R Imi.

תלמוד ירושלמי תרומות ח:ד מז.

רבי אימי איתצד בסיפסיפה (ניצוד במקום סכנה הרבה) אמר ר’ יוחנן יכרך המת בסדינו (כלומר שנתייאשו הימנו ואין לו אלא להכין לעצמו תכריכי המת), אמר ר’ שמעון בן לקיש עד דאנא קטיל אנא מתקטיל אנא איזיל ומשיזיב ליה בחיילא (שמע רשב”ל ואמר או אני אהרוג או אני נהרג אני אלך ואציל אותו בכח).

Two schools of thought have emerged from these sources. According to the first, which is the predominant opinion held by most poskim, a person is not required to endanger himself to save another because the Torah has commanded (Yoma 85b) וחי בהם – ולא שימות בהם – ‘one should live by the mitzvot and not die by them.’ This would apply to the mitzvah of lo taamod (‘do not stand idly by your neighbor’s blood’) as well. Clearly, the question of what is a risk must be asked – there are risks that a person takes very day. There are risks that a person is willing to take to preserve their property. Any action which would be a significant risk to the person would not be required. Notable poskim in this school of thought include the Sefer Hasidim (12th c. Germany):

ספר חסידים (מרגליות) סימן תרעד

כתיב (ויקרא י”ט ט”ז) ולא תעמוד על דם רעיך אבל אם הרבה מתלחמים עליו אל ישליך עצמו בסכנה ואל יעשה פשיעה בגופו ואם אדם טובע בנהר והוא כבד אל יעזור לו פן יטבע עמו.

The Sefer Hasidim concludes based on the Talmudic discussion that one should not endanger oneself in order to save another. The Rambam (12th c. Egypt) limits the requirement found in Sanhedrin to situations when “one is able (היכול)” to save, indicating that it is a qualified requirement. However, it is unclear whether the qualification is applied to the one who requires saving (whether it is possible to save him), or to the one who is saving (whether he is able to safely save the person in danger).

רמב”ם הלכות רוצח ושמירת הנפש פרק א הלכה יד

כל היכול להציל ולא הציל עובר על (ויקרא י”ט ט”ז) לא תעמוד על דם רעך, וכן הרואה את חבירו טובע בים או ליסטים באים עליו או חיה רעה באה עליו ויכול להצילו הוא בעצמו או שישכור אחרים להצילו ולא הציל, או ששמע גוים או מוסרים מחשבים עליו רעה או טומנין לו פח ולא גלה אוזן חבירו והודיעו, או שידע בגוי או באנס שהוא קובל על חבירו ויכול לפייסו בגלל חבירו ולהסיר מה שבלבו ולא פייסו, וכל כיוצא בדברים אלו, העושה אותם עובר על לא תעמוד על דם רעך.

The Meiri (13th c. Catalan) clearly states that one is required to attempt saving another only if there is no danger:

בית הבחירה סנהדרין עג עמוד א

מי שראה חברו טובע בנהר או חיה גוררתו או ליסטים באים עליו חייב להשתדל דבר בעצמו אם הוא יכול בלא סכנה.

The Tur (13/14th c.) cites the formulation of both the baraita in Sanhedrin and the Rambam.

טור חושן משפט הלכות שמירת נפש סימן תכו

א הרואה את חבירו טובע בנהר או שלסטין באין עליו חייב להצילו(א) בין בגופו בין בממונו ומיהו אם יש לו ממון להציל עצמו חייב לשלם לזה.

ב והרמב”ם כתב הרואה שחבירו טובע בנהר או שלסטין באין עליו ויכול להצילו או שישכור אחרים להצילו או ששמע שאנסים מחשבים עליו רע ולא גילה לאוזן חבירו והודיעו או שידע באנס שהוא קובל על חבירו ויכול הוא לפייסו בגלל חבירו ולהוציא שטנה מלבו ולא פייס וכל כיוצא בזה עובר על לא תעמוד על דם רעך ואם מצילו והרי כאילו קיים עולם.

The Bach (16/17th c. Poland) explains why the Tur felt the need to present the Rambam as a second opinion that conflicts with the source in Sanhedrin. He introduces the concept of danger into the explanation of the Rambam and comments that by adding the word ve’yachol the Rambam indicates that he is not required to place himself in any danger in order to save another.

ב”ח חושן משפט סימן תכו

(ב) ומ”ש והרמב”ם כתב הרואה וכו’. נראה דלפי דמלשון הברייתא משמע דחייב להצילו אפילו אינו ברור לו שיוכל להצילו חייב להכניס עצמו בספק סכנה להצילו. אבל הרמב”ם כתב ויכול להצילו וכו’ דמשמע דדוקא בדאין ספק שיכול להצילו אבל אינו חייב להכניס עצמו בספק סכנה להצלת חבירו לכך אמר והרמב”ם כתב וכו’ כנראה שחולק על מ”ש תחלה מיהו בהגת מיימוני ישנים נמצא לשם שכתב וז”ל: בירושלמי מסיק אפילו להכניס עצמו בספק סכנה עכ”ל ומביאו בית יוסף:

According to the second school of thought, a person is required to endanger himself to a certain extent. One is required to place oneself in significant danger in order to save another, even a danger that would not be normally acceptable to people in order to save their own possessions. The mitzvah of lo taamod is different than other mitvzot because it involves human life.

Following the second school of thought, The Hagahot Maimoniyot (13^th c. Germany) concludes based on the Yerushalmi that even if one must place himself in safek sakana – possible danger – one should save the other. ^[2]

הגהות מיימוניות הל’ רוצח א:טו דפוס קושטא

בירושלמי מסיק אפילו להכניס עצמו בספק סכנה.

R Yosef Karo (16th c.) in his monumental work Beit Yosef comments that even if there is a possibility of danger one is required to save the other. He explains that while one is in a situation of possible danger, the other is in definite danger, and that one who saves even one soul it is as if he saved an entire world.

בית יוסף חושן משפט סימן תכו

וכתבו הגהות מיימונית (דפ’ קושטא) עבר על לא תעמוד וכו’ בירושלמי מסיק אפילו להכניס עצמו בספק סכנה חייב ע”כ ונראה שהטעם מפני שהלה ודאי והוא ספק.

This is what he writes, as well, in the Kessef Mishneh,^[3] his commentary on the Rambam. However, in the Shulchan Aruch he does not follow this position, noting instead Yachol lehatzilo – indicating that only if he is able he must save him, and if he is unable, there is no requirement to endanger oneself.

שולחן ערוך חושן משפט סימן תכו, סעיף א

הרואה את חבירו טובע בים או ליסטים באין עליו או חיה רעה באה עליו, ויכול להצילו הוא בעצמו או שישכור אחרים להציל, ולא הציל; או ששמע עכו”ם או מוסרים מחשבים עליו רעה או טומנים לו פח ולא גילה אוזן חבירו והודיעו; או שידע בעכו”ם או באנס שהוא בא על חבירו ויכול לפייסו בגלל חבירו ולהסיר מה שבלבו ולא פייסו, וכיוצא בדברים אלו – “עובר על לא תעמוד על דם רעך”.

Much discussion is found in the Achronim about this contradiction. The Sm”a (16th c. Poland) concludes that R Yosef Karo did not follow his own logic because he saw that the three pillars of halakhic ruling, the Rambam, the Rif and the Rosh, left this out as well.

סמ”ע תכו:ב

ובהג”מ כתבו דבירושלמי מסיק דצריך אפילו להכניס עצמו בספק סכנה עבור זה והביאו הב”י וכ’ ז”ל ונראה שהטעם הוא מפני שהלה ודאי והוא ספק עכ”ל גם זה השמיטו המחבר ומור”ם ז”ל ובזה י”ל כיון שהפוסקים הרי”ף והרמב”ם והרא”ש והטור לא הביאו בפסקיהן מ”ה השמיטוהו ג”כ.

In the 13th century (Italy), Menachem ben Benjamin Recanati wrote a responsum debating the appropriate response to a ruler who demanded the sacrifice of a limb (in a way that will not be fatal) from a Jew in order to save a fellow Jew. Is this comparable to organ donation? The situation relates to one Jew in danger, and another who will sacrifice part of his body to save him. The premise is that the loss of the limb will not be fatal. We can say that this is a similar case, although not precisely comparable.

ספר ריקנאטי תע

אם אמר השלטון לישראל הנח לי לקצץ לך אבר אחד שאינך מת ממנו או אמית ישראל חבירך יש אומרים שחייב להניח לקצץ לו האבר והואיל ואינו מת. וראי’ מדאמרי’ בע”ז החש בעינו מותר לכוחלת בשבת ומרפש טעמא דשורייקא דעינא בלבא תלו משמע הא אבר אחר לא והשתא יבא הנידון מק”ו ומה שבת שחמורה שאין אבר אחר דוחה אותה היא נדחית מפני פקוח נפש. אבר אחד שנדחה מפני השבת אינו דין שתדחה מפני פקוח נפש.

Recanati says that it is logical that one would be required to allow the limb to be cut off, based on a Talmud in Avoda Zara 28 which allows one to treat an eye sickness on Shabbat only because the eye was thought to be connected to the heart and could cause a loss of life. Thus, if the loss of a different limb would not endanger a life, one would not be able to violate the Shabbat to save it. He says that one can deduce by kal vachomer that if we can violate the Shabbat for pikuach nefesh, but not to save another limb, that limb should be sacrificed for pikuach nefesh.

Based on the Recanati, the Radbaz (16th c. Israel/Egypt), who was contemporaneous with the Shulchan Aruch, was asked the same question. He rejected the thesis posited by Recanati that requires the Jew to allow the limb to be cut off. Recanati’s logic was based on a comparison to a person’s obligation to forfeit a limb on Shabbat if the loss would not kill him. Recanati explains that pikuach nefesh takes precedence over the laws of Shabbat but the laws of Shabbat take precedence over the loss of a limb. The Radbaz differentiates the case of Shabbat from the question regarding the ruler, since on Shabbat the obligation to forfeit the limb stems from the fact that God Himself has endangered the limb and the danger already exists. However, he says, one cannot conclude from this that one must also elect to forfeit a limb in a case where the danger is not already present, and not divine. Therefore, he rules that allowing one’s limb to be cut off in order to save another is a pious act, but not an act that can be mandated. The Radbaz views the act of sacrificing the limb in order to save the life of the threatened person as an act of piety, midat chassidut, which indicates approval and praise but not obligation.

שו”ת רדב”ז חלק ג סימן תרכז

תשובה זו מדת חסידות אבל לדין יש תשובה מה לסכנת אבר דשבת שכן אונס דאתי משמיא ולפיכך אין סכנת אבר דוחה שבת אבל שיביא הוא האונס עליו מפני חבירו לא שמענו.

Additionally, the Radbaz points out that the reality is that one cannot say unequivocally that the removal of a limb is not life threatening. Even minor surgery has its complications, and one cannot be obligated to put oneself at risk that might result in death. He brings the example of a blood–letter who made minor cuts on a patient’s ear and the patient bled to death.

There is some debate regarding the question of whether endangering a limb by definition constitutes endangering one’s life. The Shulchan Aruch,^[4] and many in his wake, rules that endangering a limb does not by definition constitute endangering one’s life. The Shach^[5] comments that one does not need to endanger a limb to save another, perhaps because he does view endangering a limb as life–endangering.

ותו דילמא ע”י חתיכת אבר אעפ”י שאין הנשמה תלויה בו שמא יצא ממנו דם הרבה וימות ומאי חזית דדם חבירו סומק טפי דילמא דמא דידיה סומק טפי. ואני ראיתי אחד שמת ע”י שסרטו את אזנו שריטות דקות להוציא מהם דם ויצא כ”כ עד שמת והרי אין לך באדם אבר קל כאוזן וכ”ש אם יחתכו אותו.

The Radbaz also points out that one is required to save another by expending money, but not by endangering one’s limbs. Even the Torah, that states “a burn for a burn, a wound for a wound” (Shemot 21:25) means practically that one should pay the value of the limb. He comments that it would be more far–fetched for someone to die of a burn than sacrifice of a limb, but even in the case of the burn the Torah requires only payment.

… שאינו מחוייב למסור עצמו על הצלתו אף על גב דחייב להצילו בממונו אבל לא בסכנת איבריו…

ותו דהתורה אמרה פצע תחת פצע כויה תחת כויה ואפ”ה חששו שמא ע”י הכוייה ימות והתורה אמרה עין תחת עין ולא נפש ועין תחת עין ולכך אמרו שמשלם ממון והדבר ברור שיותר רחוק הוא שימות מן הכויה יותר מעל ידי חתיכת אבר ואפ”ה חיישינן לה כ”ש בנ”ד. תדע דסכנת אבר חמירא דהא התירו לחלל עליה את השבת בכל מלאכות שהם מדבריהם אפילו ע”י ישראל.

Additionally, the Radbaz writes that the Torah has ways of pleasantness (דרכיה דרכי נעם) and thus could not obligate one to forfeit a limb.

ותו דכתיב דרכיה דרכי נועם וצריך שמשפטי תורתינו יהיו מסכימים אל השכל והסברא ואיך יעלה על דעתנו שיניח אדם לסמא את עינו או לחתוך את ידו או רגלו כדי שלא ימיתו את חבירו.

Based on this reasoning, the Radbaz concludes that there is no obligation to sacrifice a limb, but that this is a pious act. However, he does note that if the sacrifice would endanger a life that would fall under the category of chassid shoteh – a pious fool. He states that the prohibition to put oneself at risk takes precedence over even the certainty of another’s danger. This seems to be based on the opinion of Rabbi Akiva in Bava Metzia 62a – ‘Your life takes precedence over the life of your fellow.’ Based on this, he would never require one to sacrifice a limb for another.

הלכך איני רואה טעם לדין זה אלא מדת חסידות ואשרי חלקו מי שיוכל לעמוד בזה ואם יש ספק סכנת נפשות הרי זה חסיד שוטה דספיקא דידיה עדיף מוודאי דחבריה. והנראה לע”ד כתבתי:

In another responsum,^[6] the Radbaz discusses the question of putting oneself in danger to save another and concludes that the obligation to endanger oneself is dependent on the level of risk. If the risk is minimal or nonexistent, one would be obligated. He bases this ruling on the Yerushalmi. If the risk is extreme it would be prohibited; he would be a chassid shoteh. In the case when the risk is not clear but is less than 50% one would be permitted, but not required. However, this would not be applicable to sacrificing a limb, which according to the Radbaz is always voluntary.

The Radbaz’s position was upheld over the years by many authorities, with few notable exceptions such as the Chavot Yair^[7] (17th c.) and the Nishmat Chaim^[8] (17th c.), who followed the thought of the Beit Yosef. Authorities who follow the Radbaz include the Shulchan Aruch HaRav^[9] (18th c.) who is particularly cautious saying that one must not take any risk to themselves, as the Torah proscribes, וחי בהם. While the Agudat Eizov^[10] (19th c. Poland), follows the Radbaz, he points out that one must carefully evaluate the danger involved. He brings a source from the Gemara in Niddah 4, where R Tarfon denies refuge to some people who were being sought out by the ruler, because R Tarfon felt that aiding them would put him at risk. However, he ends by saying that it is mandatory to carefully evaluate the matter as to whether or not there really is danger, and not to be too quick to decide that there may be danger. He concludes that the Talmud (Bava Metzia 33a) warns against this by stating that ‘one who is too cautious in fulfilling [the law that the protection of one’s own possessions takes precedence over the possessions of others] is destined to end up in a state of need.’ The Aruch HaShulchan^[11] is also concerned that a person might not be careful enough, and rule that there is danger where there is none, avoiding the effort to save another.

While the Sheilat David^[12] (19th c.) writes that one is not required to endanger oneself, the Minchat Yitzchak^[13] (20th c.) rules that one is not allowed to endanger oneself. R Meir Simcha of Dvinsk (20th c.) in Ohr Sameach^[14] on Hilchot Rotzeach and in the Meshech Chochma,^[15] supports this position, based on the Rambam who in the discussion regarding ir miklat (cities of refuge) rules that one may not leave the city of refuge even if all of Israel are in need of his help, since that would be surrendering himself to death, i.e. he must not leave because that would put him in danger.

Based on the halakhic development described above, in ruling on the question of organ donation, modern day poskim have grappled with the question whether one is permitted to donate an organ, since there is a risk for the donor. Since the definition of ‘acceptable risk’ has not been agreed upon, there has been some debate on the matter. Rabbi Akiva Eiger^[16] proposed that a risk of one in a thousand is considered to be high enough to allow a violation of a Torah prohibition.

It is interesting to examine the halakhic development in this matter in tandem with the development of medical capabilities. In the early days of transplantation, the risk to both the donor and the recipient were significantly higher than they are with today’s medical technology. This clearly affected psak on the matter.

In 1961, the Minchat Yitzchak^[17] forbade the donation of a kidney both because of the immediate danger involved in the procedure, and due to concern for possible future problems.

In 1967, R Moshe Feinstein in the Igrot Moshe^[18] permitted an organ donation to save another life despite the lack of obligation in his opinion, even assuming that there is a significant risk to the donor.

R Waldenberg in the Tzitz Eliezer^[19] grappled with this question and reviewed the sources. As previously mentioned, his reading of the Hagahot Maimoniyot is that his ruling would only apply in a case where the danger is preexisting, and not in a case in which one puts himself in danger. This thought echoes the Radbaz’s rejection of Recanati. He viewed the removal of a limb as a situation of vaday – definite – rather than safek – possible – danger, since it is certain that the limb will be lost. Thus, R Waldenberg viewed the operation to remove the organ as too risky to permit, although he left an opening for scientific advances that would assure a lower risk. In this case he would permit, but not require, organ donation. In a later response, ^[20]he wrote that if the danger of removing the organ is not certain, and medical science concludes that both will remain alive, one would be allowed to voluntarily donate an organ under certain circumstances.

In 1980 R Ovadia Yosef^[21] summarized the positions brought above and concluded that in his time doctors report that 99% of donors made a complete recovery, and therefore the reasoning of the earlier poskim that one should not put themselves in danger was no longer valid. He thus concluded that it is not only permissible to donate a kidney but it is a mitzvah to save another person. However, based on the Radbaz’s conclusion that one cannot be obligated to donate an organ, donation cannot be required.

In 1981 R Moshe Meiselman^[22] permitted kidney donation when there is a 50% chance or higher to extend the recipient’s life, and when donation will improve quality of life over dialysis. However, if there are any other complications, or expectations are below 50%, one must judge each case to see if it is permitted or prohibited.

R Shlomo Zalman Auerbach^[23] ruled that if the ill patient is present it is certainly permissible for a person to undergo suffering, for example, by donating his kidney, in order to save the life of the patient.

With today’s technology, it would seem that the reservations of most poskim could be assuaged, and even those who were reluctant to permit donation might permit organ donation, even viewing donation as a pious act that should be encouraged. With scientific developments and better medical understanding, the lowering of risk, and better understanding by poskim, it has become an accepted ruling that organ donation is an act of piety, but not a requirement.

Is Donation Required?

I would like to explore the possibility that with the advances in medicine, the question that should be asked is no longer whether organ donation is permissible, but rather whether it might be obligatory to save another by donating an organ or other tissue.

Rabbi Dr. Edward Reichman^[24] reports a case of a young woman in Israel who participated in a bone marrow drive and was found to be a match for a patient. She agreed to donate her bone marrow and was retested to confirm that she was an appropriate match. In order to receive a bone marrow transplantation the patient’s bone marrow must be eradicated by irradiation. The irradiation procedure leaves the patient in a very fragile state with no bone marrow at all. In anticipation of the transplant the patient underwent irradiation. At that stage, the donor regretted her decision to donate and refused to continue the process. This left the patient facing certain death. Could the rabbis have coerced the donor to make the donation? Or is it halakhically prohibited to coerce someone into donating a part of one’s body? In this case, many rabbis tried diligently to persuade the donor to continue the donation process and were unsuccessful. The patient died as a result. After the woman died, R Sternbuch reportedly said that maybe she should have been coerced. While this example is extreme and involves the potential donor actively placing the patient at risk, it demonstrates that there may be cases where even organ donation could be required.

There are many factors to consider when approaching this question. We will explore some of those cited by modern day poskim.

A. Value

The Radbaz categorically states that one cannot be required to donate an organ, even in a situation where there is certain pikuach nefesh for another Jew. He does not explain why, but only states that ‘the Torah’s ways are pleasant.’ However, it seems he believes the obligation to save a life is limited, as in most mitzvoth. In general, fulfilling a positive commandment requires one to spend up to one–fifth of one’s possessions. A negative (prohibitive) commandment would obligate one to spend the value of all of one’s possessions. Which of these categories defines organ donation? The mitzvah of lo taamod is in an intermediary category of שב ואל תעשה (literally, ‘sit and do no action’) – since there is no action in the violation, rather it is the failure to perform an action. There is a debate among the rabbis whether this is treated as a positive commandment which requires spending only one fifth of assets, or as a prohibition which would require spending everything. The majority of poskim believe that the level of obligation in the case of שב ואל תעשה –is similar to that of a positive commandment, and therefore only requires one to expend the value of one–fifth of one’s property. Although organ donation cannot be translated into a monetary burden, Chazal did assess hypothetical value for how much one would be willing to risk to avoid a situation. We can assume that if people would willingly spend one–fifth of their worth to avoid a situation, they would not be required to fulfill the mitzvah. Thus, the Radbaz’s reasoning seems to be that most people would willingly part with one fifth of their worth and even all of their wealth to avoid losing a limb, and therefore there can be no mitzvah requirement to lose a limb, but it would be considered a pious act.^{[25] [26]}

On the other hand, one might argue that this concept of valuation should not apply to the mitzvah of lo taamod, since the act involved is not merely any mitzvah, but saving a person’s life. Judaism considers every person to be an entire world.^[27] The Talmud in Yoma 84b discusses cases in which one desecrates Shabbat for pikuach nefesh and determines that one may desecrate Shabbat on behalf of someone who will in turn be able to keep more Shabbatot in the future. Similarly, one could argue that by donating an organ one is not just saving this person’s life but enabling him to continue to perform mitzvot. Thus, the “value” of the donation goes far beyond the singular action.

יומא פד:

ר’ שמעון בן מנסיא אומר (שמות לא, טז) ושמרו בני ישראל את השבת אמרה תורה חלל עליו שבת אחת כדי שישמור שבתות הרבה.

B. Regenerative Organs

Many of the donations today are regenerative, and would therefore not fall under the Radbaz’s definition of an organ that cannot be required to be donated: since the donation is relatively harmless, it would not be considered a burden equal to one–fifth of one’s possessions.

R Willig and R Bleich^[28] have both stated that in the case of regenerative body parts, where there is no significant danger in the donation process, there would be a full obligation to donate when the person in need of donation is not theoretical, but actually present (חולה בפנינו). R Elyashiv^[29] ruled that if general anesthesia was needed in order to give the donation that would be considered enough of a risk to say that one could not be obligated to donate. R Willig and R Bleich view the risk of anesthesia as an insignificant risk. R Meiselman^[30] states clearly that while organ donation is permitted and voluntary, blood and skin donation are obligatory as they do not have enough of a “monetary value” to exempt one from the obligation.

R Shaul Yisraeli^[31] does not require donation, as he does not view it as part of the mitzvah of והשבות לו – returning to the recipient something that was once his.

C. Pain and Suffering

The Nishmat Avraham^[32] writes that despite the fact that one cannot say that there is really a risk to a bone marrow donor, there is pain and discomfort and an element of risk because of the necessity to undergo anesthesia. He quotes a letter he received from R Shlomo Zalman Auerbach that states that one must explain to the reluctant donor that it is a mitzvah to donate and if the chance of saving the patient is greater than 50% he should beg him to be strong and perform the great mitzvah of pikuach nefesh. However, one must not apply even psychological or social pressure, or coerce the donor in any way, because there is a small element of danger involved. However, in a case where there is no danger and only pain and discomfort one may be required to suffer in order to save another if there is no one else who can save the patient.

R Shlomo Zalman Auerbach bases his understanding on the Talmud in Shabbat 33, in which R Shimon bar Yochai and his son sit in the Beit Midrash and learn Torah against the Roman decree, while R Shimon bar Yochai’s wife supplies them with food. When the decree intensifies, R Shimon bar Yochai decides to go to hide in a cave to escape the Romans, with the explanation that women are not strong enough to undergo the torture the Romans would inflict, and his wife would reveal their actions if caught. From this Talmud he understands that a person must undergo suffering to save another in the case where there is no danger to life. A similar argument is given using as proof the fact that a woman can be compelled to breastfeed her child, despite the fact that breastfeeding often involves pain. The Magen Avraham^[33] and the Netziv^[34] agree that a person is required to undergo suffering (included in this are pain, illness and embarrassment) to save the life of another. Thus, donations such as blood and blood components (thrombocytes, stem cells, plasma, platelets) which are done through blood withdrawal or pheresis would fall under the category of donations that one could compel a donor to give.

R Wosner^[35] was asked about donating blood, since this procedure weakens the donor. He differentiates between the donor exposing himself to illness with risk (חולה שיש בו סכנה) as opposed to illness without risk (חולה שאין בו סכנה). If the donor is not putting himself into a situation which would be halakhically considered dangerous he would be required to donate blood. R Wosner is less certain about the situation of pheresis used for platelets and stem cells. Here he is reluctant to say that one may be required, although from his formulation it seems that if he was convinced that the procedure was not dangerous he might agree that there is an obligation.

Rabbi Naftali Bar Ilan^[36] points out that not only is there an obligation to suffer on behalf of another, Beit Din can even force a donor to comply. This is learned by kal vachomer from the mitzvah of tzedaka. Tzedaka is an example of a mitzvah which is said to have מתן שכרה בצדה (its reward is explicitly stated along with the mitzvah), a category of mitzvot which the Beit Din does not normally force one to perform, but nonetheless in the case of tzedaka the Beit Din compels people. Two reasons are given for compelling one to give tzedaka: firstly, because there is an element of prohibition, and secondly, because of the great need of the poor people. If the Beit Din overrides the general rule of מתן שכרה בצדה for these reasons, it seems obvious that they should compel a donor in a mitzvah which is not מתן שכרה בצדה, where both reasons apply. Thus he learns that one may compel a donor to donate blood marrow. The Tzafnat Paaneach^[37] writes that even those Rishonim who don’t agree that one can be forced to give tzedaka, are in agreement that one can be compelled to support a needy family member, based on the Rambam who believes that there is a Torah obligation to give tzedaka to a family member first. Similarly, even according to one who normally would not require donation, a family member in need of a donation could compel a relative to give the donation.

D. Choleh Lefanenu

Another consideration for permitting a donation is the concept of חולה מסוכן לפנינו – ‘a dangerously ill person is before us.’ The Noda Beyehuda^[38] limits pikuach nefesh to cases in which there is a dangerously ill person present before us. In such cases it has been permitted to perform autopsies, which are normally prohibited by halakha because they constitute nivul hameit – ‘desecrating the corpse.’ Similarly, if there is a specific person present who is dangerously ill and can be saved by donation, an argument could be made that the requirements of pikuach nefesh come into effect. Additionally, in the case of organ donation, there is always a choleh lefaneinu – one doesn’t donate an organ without knowing it is needed. However, blood and blood components are often donated to a blood bank where there is no immediate recipient.

The concept of choleh lefaneinu must be redefined in today’s global village culture, where a patient is not limited to donations from the local population, and where medical knowledge can be rapidly shared all over the world. This redefinition of the Noda BeYehuda’s concept has been termed רחוקים נעשו קרובים – ‘the far have become near.’ This can be applied both in time and space. Rabbi Yechiel Yaakov Weinberg^[39], argues that the definition of choleh lefanenu may be expanded due to the major improvement in worldwide communication. The Chazon Ish^[40] ruled that if a disease is common, we can presume there are others currently suffering from it, and that we can permit an autopsy on a patient who died of this disease. R Uziel‘s^[41] ruling was even broader. In his opinion since we have hospitals full of ill people one can always assume there is a choleh lefaneinu.

This opinion was not accepted by all, in particular with regards to autopsy. The Nishmat Avraham^[42] writes that an autopsy will not provide help to the choleh lefaneinu because any medical knowledge obtained would not be implemented without first being published and reviewed, a process which takes months to years. Thus, the time–factor is the problem, and should there be someone who could in some way be helped immediately he would concur that a post mortem would be allowed. This would include most cases of organ donation.

The broad concept of חולה מסוכן לפנינו can compel donation especially in a case where the donor population is limited. In blood donation, most blood types are widely available. However, particularly in bone marrow donation the chance of having a donor match is quite rare – 1:10,000. Because of the rarity of a match, it is a mitzvah which אינה יכולה להעשות על ידי אחר – ‘cannot be done by someone else.’ R Moshe Halberstam^[43] writes that in a case of pikuach nefesh which cannot be done by another, it is a mitzvah to sacrifice part of one’s body for this purpose. Based on this, R Chaim Pinchas Sheinberg^[44] writes that one can compel another to donate. It is important to note, that while these authorities would require donation if someone was found to be an appropriate match, there is no halakhic basis for requiring someone to be tested for compatibility, because the chance of matching with a person in need is so rare, although it is clearly a pious act to do so.

Donation to a blood bank would be a classic case of not having a חולה בפנינו and therefore, one would not be required to donate to a blood bank, although it would be considered a pious act. One might rule that if there is a shortage of units in the blood bank there could be cause to say that one is required to donate blood.

E. Opposition to Blood Donation

R Waldenberg^[45] opposes requiring blood donation, based on three points: 1) In the case of blood, the Torah writes “כי נפש הבשר בדם הוא” – ‘the soul of flesh is in the blood.’ It is his position that giving more than a revi’it of blood is the equivalent of giving one’s life. 2) Based on the Talmud in Sanhedrin, he understands that the requirement to save another person refers to use of physical power, not mutilating one’s body. Thus, even if there is a חולה לפניו and he has a rare blood type, we cannot compel him to donate. 3) Similarly to the Radbaz, he argues that a person must be careful, since even a small risk could become greater. While there is very minimal risk to a blood donor, adverse reactions such as a vasovagal syncope can cause complications.

Conclusion

Factors which have to be considered in the question of requiring donation include:

Does the organ or tissue regenerate?

Is there pain involved?

Is there a choleh – critically ill person – before us?

To what extent does the donor place himself at risk for the procedure?

In the case of donations which regenerate (and therefore, would not fall under the Radbaz’s declaration that one cannot require another to donate an organ), with the broad definition of חולה לפנינו which technology provides, and with the low risks associated with today’s medical procedures of organ donation, it would appear that one could require the donation of regenerative tissues. Based on the earlier explanation of the types of donation, the donations can be placed on a spectrum such that donation of blood would be the simplest to require, while donation of a kidney would be at the other extreme, not required but certainly permitted and a pious act. Blood marrow and liver donations would be on the spectrum closer to blood donations as they regenerate, while lung donations would be more similar to kidney donations that do not regenerate. When grappling with questions of organ donation, one must constantly be aware of technological innovations and medical advancements that can affect our halakhic rulings in questions of risk and pikuach nefesh.

Footnotes

^[1]    In an oral communique with Dr. Isaac Stillman, a nephropathologist at Beth Israel Deaconess Hospital, he wished to express that the data suggests that while donation does not diminish life expectancy, there is some risk which is difficult to quantify.

^[2]    The Tzitz Eliezer’s reading of the Hagahot maimoniyot is that the psak of the Hagahot maimoniyot would only apply in a case where the danger already exists, but not where he himself is creating the danger.

^[3]     כסף משנה הלכות רוצח ושמירת הנפש פרק א הלכה יד

^[4]     שולחן ערוך אורח חיים הלכות שבת סימן שכח סעיף יז.

^[5]     ש”ך יורה דעה סימן קנז ס”ק ג.

^[6]     שו”ת רדב”ז חלק ה ללשונות הרמב”ם סימן ריח (אלף תקפב).

^[7]     שו”ת חוות יאיר סימן קמו.

^[8]     נשמת חיים חלק הדרושים י”א.

^[9]     אורח חיים סימן שכט.

^[10]    אגודת אזוב לח.

^[11]    ערוך השולחן חושן משפט סימן תכו סעיף ד.

^[12]    שאילת דוד, אהע”ז ס’ ו הע’ ד.

^[13]    מנחת יצחק ו:קג.

^[14]    אור שמח הלכות רוצח ושמירת הנפש פרק ז הלכה ח.

^[15]    משך חכמה שמות פרק ד פסוק יט.

^[16]    שו”ת רבי עקיבא איגר פסקים ס’ס.

^[17]    שו”ת מנחת יצחק ח”ג סי’ מ”ו.

^[18]    יו”ד ח”ב סי’ קע”ד.

^[19]    חלק ט סימן מה.

^[20]    ציץ אליעזר חלק י סימן כה.

^[21]    יחווה דעת ח”ג סי’ פ”ד.

^[22]    הלכה ורפואה תשמ”א – בעיות הלכתיות בענין השתלת כליות.

^[23]    נשמת אברהם חלק ב יורה דעה.

^[24]   Oral communication, in a shiur given at Yeshiva University.

^[25]   Tradition 27:3 Survey of Recent Halakhic Periodical Literature, J. David Bleich.

^[26]    הלכה ורפואה תשמ”א – בעיות הלכתיות בענין השתלת כליות.

^[27]    משנה מסכת סנהדרין (ד:ה).

^[28]   As quoted in oral communications of 2006, in Halachic Issues in Determination of Death and Organ Transplantation, 2010, Section X.

^[29]   As quoted in Halachic Issues in Determination of Death and Organ Transplantation, 2010, Section V.

^[30]    הלכה ורפואה ב – קיח.

^[31]    תרומת איברים מאדם חי – סיכון התורם וקבלת תשלום, הרב שאול ישראלי, אזיא נ”ז-נ”ח כסלו תשנ”ז.

^[32]    אבן העזר סימן פ.

^[33]    סוס”י רמו.

^[34]    קכט ד.

^[35]    הרב שמואל הלוי ואזנר, בגדר חובת הצלה לזולת שיגרום לתורם חולשת הגוף וטורח, הלכה ורפואה ד.

^[36]    תרומת מח עצם – היבטים הלכתיים, מכון שלזינגר,1992.

^[37]    צפנת פענח על הלכות מתנות עניים ז א.

^[38]    שו”ת נודע ביהודה מהדורא תניינא – יורה דעה סימן רי.

^[39]    תחומין 12:382-384 (1991).

^[40]    חזון איש יורה דעה ר”ח:ז, אהלות כב, לב.

^[41]    משפטי עוזיאל יורה דעה א:כח-כט.

^[42]    נשמת אברהם ב יורה דעה.

^[43]    מצוטט בספר בדמיך חיי.

^[44]    מובא בספר בדמיך חיי עמ’ 126.

^[45]    ציץ אליעזר יג, קא, הלכה ורפואה ד קמג.