Organ Donation in Orthodox Christianity: Prohibited, Permitted, or Morally Required?

Orthodox Christian ethics focuses on one thing above all: “Be perfect, therefore, as your heavenly Father is perfect” (Mt. 5:48). If ethics addresses questions such as “How should I live?” and “What should I do?” then the answer is: Do what is necessary to restore the image of God in yourself and become united with God in this life and the next. The guiding principles in all of this are provided by Christ, who summarized the Law and the Prophets: “Love the Lord your God with all your heart and with all your soul and with all your mind” and “Love your neighbor as yourself.” (Mt. 22:37-38) For human beings, this is both the path to perfection and precisely what it means to be perfect; when the image of God is restored in us, we reflect God’s love to others. We acquire the strength to love God and others generously in our actions through participation in Liturgy, Confession, fasting, prayer of the heart, obedience, almsgiving, and other forms of participation in the life of the Church.

All of this is well-travelled ground. But how does this general approach to becoming good help us as we ask questions about healthcare technologies that no Church Father imagined and no scriptural passage or liturgical hymn mentions? One such technology is organ transplantation. By mechanically ventilating bodies and performing complex surgeries, we may replace an individual’s failing organs with those of another human being. This was, of course, impossible throughout most of human history, but it is commonplace today. We have now performed over one million solid organ transplantations in the U.S. alone.^[1]

Orthodox bioethics brings medical information about issues such as organ transplantation into dialogue with the Orthodox Tradition to assist the faithful in making decisions regarding such technologies.^[2] This is much needed because, in my experience, Orthodox Christians are commonly uncertain about organ donation, wondering: Is it prohibited, permitted, or maybe even morally required?

The Orthodox Christian Case for Organ Donation

Organ donation saves lives in the ordinary sense of the term. If I am drowning and you throw me a life preserver, you have saved my life even though I will surely die some years later. Similarly, someone with end-stage liver disease, kidney failure, or heart failure will typically die of their condition without a transplant. In her book, In God’s Hands, the Orthodox mother and teacher, Elissa Bjeletich Davis, tells the story of her youngest daughter, who experienced liver failure and would have died before the end of her first year without a liver transplant.

During his ministry on earth, Jesus healed people both spiritually and bodily. Healing was an act of compassion (Mt. 14:14, 20:34) and a demonstration of the Father’s work through the Son (Jn. 11:40-41). After Pentecost, the Apostles continued his healing ministry (Acts). Organ donation would appear to belong to this Christian tradition of healing. It can be a tangible demonstration of compassion and love of the dying neighbor.

It is also a way of practicing Christian hospitality. Fr. Rabee Toumi, an Orthodox bioethicist, reminds us that “Hospitality in its Greek origin, philoxenia, the love of the stranger, is central to [our] worldly mission” since it aspires to bring “estranged humanity back to God through Christ’s incarnation.”^[3] In contrast to living organ donation, which is typically directed to a specific person, deceased donation is almost always donation to the stranger. Davis describes this aspect of hospitality as she waited for a donated liver for her daughter:

I’ve lost a child…. I know how that feels, and I cannot tell you how much it astonishes me that parents can make the choice to give life to other children at the very moment when their own child dies…. These parents step outside of themselves and show love to people they’ve never met, to parents sitting vigil in quiet rooms, praying for miracles. Today, we sit patiently and wait to receive the greatest gift—literally, the gift of life—from someone we’ve never met. We are totally dependent on the kindness of strangers.^[4]

I believe that taken together, the commandment to “love your neighbor,” the Orthodox virtue of hospitality, and the healing ministry of Christ, which became his Apostles’ ministry, create a strong presumption in favor of organ donation.

Accordingly, I will spend the remainder of this article examining a series of concerns with organ donation. These are concerns that Orthodox Christians may want to resolve prior to deciding about organ donation. However, before examining these concerns it would be helpful to review briefly the two major pathways to organ donation in the US.

Who Is Actually Eligible to Donate Organs After Death?

Most people assume that if they agree to organ donation, then their organs will be procured following their death. However, less than one percent of people who die in a given year are actually eligible.^[5] Organ donation requires something rare: An individual must die while leaving behind organs that are relatively healthy. When people die of the most common causes of death—heart disease and cancer—usually their organs are not healthy. Even when someone who is relatively healthy dies, their organs will ordinarily die with them in a very short amount of time because they are not receiving oxygen.^[6]

The most common causes of the death of actual organ donors are gunshot injuries, opioid overdoses, and traumatic head injury from motor vehicle accidents. The thing that most organ donors share in common is being on a ventilator following attempted resuscitation. According to U.S. law, individuals may be declared dead while still on the ventilator if tests indicate that they have permanently lost all major brain functions—consciousness, the ability to breathe, and brainstem reflexes.^[7] Most organ donors are declared dead using these neurological or “brain death” criteria.

Apart from brain death, potential organ donors might be declared dead after the ventilator is removed once they have permanently lost circulation. This can enable so-called “donation after a circulatory determination of death” or DCD.^[8] The most common form of DCD in the U.S. is called “controlled.” Ordinarily, patients are eligible to donate if they were relatively healthy prior to ending up on a ventilator (e.g., due to stroke or head trauma). Most DCD donors are profoundly brain injured prior to being placed on the ventilator, and the family or proxy decision-maker decides to withdraw mechanical ventilation because there is no chance of recovering consciousness. The most recent international consensus guidelines recommend that DCD donors are not declared dead until after the ventilator is removed, breathing has stopped, and circulation has been lost for at least five minutes.^[9] Most DCD protocols say a patient is eligible to donate organs only if death follows removal of the ventilator within a specific amount of time—commonly 60 or 90 minutes. Otherwise, organs are often damaged from inadequate (rather than absent) respiration and circulation. Predicting who will meet this third criterion is often difficult.

Exploring Concerns with Organ Donation

Before presenting what Eastern Orthodox synods of bishops have taught on organ donation, I want to examine briefly five questions that commonly arise in Christian circles when discussing organ donation.

1. Is brain death really death? Might organ donation actually cause death?^[10]

As noted already, when organ donation follows a declaration of brain death, the body is being maintained on a ventilator. It is still pink, warm, and capable of processing urine. In short, the body shows many signs of life, which leads some people to question whether brain-dead donors are truly dead. On this, Tristram Engelhardt, Jr., an Orthodox bioethicist and physician, writes:

After the early periods of gestation, when a person’s brain is destroyed, that person is dead, although certain human biological life may continue in cell cultures, tissues, and organs. The remains of the body can be transplanted without transplanting the person. The kind of human life sustained in cells, tissues, organs, and even in decapitated bodies is not that of a person.^[11]

Similarly, Fr. John Breck writes:

From a Christian perspective the most basic requirement for “personhood” is the unity of the body and soul. However we may define “soul,” it is clearly related to the brain function (although it is certainly not limited to that). That is, once “brain death” occurs, the organism is dead.^[12]

Both Engelhardt and Breck offer their support for whole brain death criteria. These criteria do not exclude survival of some brain functions; rather, they focus on the permanent loss of two central features of the human being: the capacity for consciousness and the ability to breathe.^{[13], [14]}

Please note that brain death is not the same as a persistent or permanent vegetative state (PVS). Terri Schiavo is perhaps the most famous case of a patient in a PVS. Patients in a PVS commonly have their eyes open, retain brain reflexes, and breathe spontaneously.^[15] It is important that we continue as a nation to reject the use of higher-brain-death criteria, which would include patients in a PVS, who can still breathe spontaneously. This is out of respect for the significance of breath. From a theological perspective, the recent work of Matthieu Pageau on symbolism in the Genesis creation narratives is instructive:

In the story of the Garden of Eden, humanity is described as a microcosm of creation. Thus, Adam is created by joining a body from the earth and a breath from heaven. … the word ‘spirit’ simultaneously refers to the wind of heaven and the breath of living creatures. These are one and the same in biblical cosmology.^[16]

Moreover, breath is closely tied to the ability of the conscious mind to express itself: We cannot speak without breath. Accordingly, within Pageau’s interpretation of the creation of Adam, the head represents “the source of meaning for the body” given its link to breath.^[17]

2. Are DCD or circulatory criteria sufficient to ensure the donor has died prior to donation?

What about DCD, which involves removing the ventilator and waiting approximately five minutes after the loss of circulation before determining death? First, DCD should occur only when there is no meaningful chance to restore the individual to health, and when the decision to withdraw the ventilator is appropriate. Regarding the use of circulatory criteria to determine death, the latest international consensus statement offers a view that I think is not problematic for Orthodox Christians: Once we ascertain that circulation is permanently lost, e.g., by waiting for at least five minutes, to rule out the possibility that circulation might spontaneously resume, then we have also ascertained that brain functions are permanently lost.^[18] Major brain functions are lost very quickly after circulation is lost—e.g., consciousness, spontaneous respiration, and reflexes are lost within 30 seconds or fewer. If circulation is permanently lost, then so too are these neurological functions. Therefore, DCD criteria may be used for reasons similar to those offered on behalf of brain death.

3. Is it sacrilegious to cut up and remove organs from a body that is sanctified by the sacraments?

The Orthodox Christian tradition forbids cremation.^[19] Deacon Mark Barna, author of A Christian Ending, explains that all bodies are sacred insofar as they preserve the image of God, but the body of one who was baptized, anointed, and received the Eucharist is particularly sacred and must be treated as such. Cremation destroys the body, whereas traditional burial—without the embalming and the concrete vaults widely used in the US—permits the body to return quickly to the earth from which it came. Orthodox funeral rituals require the presence of a body.^[20]

This might seem to speak against organ and tissue donation, which involves surgical removal of solid organs, intestine, some skin, some bone, corneas, and other tissues. The Orthodox moral theologian, Fr. John Breck, notes that some Orthodox Christians have opposed organ donation for this reason.^[21]

However, there are several considerations that make this conclusion questionable. First, cremation is not motivated by love, hospitality, and the desire to extend Christ’s healing mission. Second, there is precedence within the Orthodox tradition for using pieces of the deceased body for healing, namely, relics. Pilgrims frequently travel to visit relics that have been associated with physical healing. Relics may range from a whole incorrupt body, a skull, or bones, to even desiccated portions of the body such as fingers. Thus, we know it is possible to use portions of a deceased body for the purpose of healing in a spirit of love and respect.

Finally, in the Book of Needs, we read a prayer for those about to undergo an operation:

O Lord Jesus Christ our God, Who patiently endured the scourging and wounding of Your most-holy Body, so that You might save the souls and bodies of Your people: Look graciously, we beseech You, upon the suffering body of this Your servant…granting that she may so endure her sufferings in the flesh, that the wounding of her body may serve for the correcting and salvation of her soul.^[22]

This illustrates two further points: First, Christ allowed his body to be cut and wounded for the healing of others; and second, every surgery patient does the same for the healing of their own bodies. How much more then is it permissible for us to undergo some degree of bodily harm after death to save the life of another?

4. Is organ donation incompatible with Orthodox funeral rituals, which ordinarily involve an open casket and prompt burial?

Organ donation can lead to some delays—about one day on average—in delivering a body to a funeral home or similar destination. However, it generally does not preclude a prompt burial without embalming, nor an open casket funeral.^[23] The process of achieving this may not seem very natural—the organ procurement organization may use PVC piping to replace removed bone; desiccants may be applied where skin was removed to prevent oozing; and plastics may need to be placed underneath garments. But then death never is very natural. Even in his book A Christian Ending, which describes a traditional Orthodox approach to burial, Deacon Barna talks about the need to use ice sometimes to reduce the risk of odors and to superglue lips together to keep a jaw closed. As he says, death is not natural—this is not how things were meant to be. It is ugly, and it is the main consequence of original sin.^[24]

5. Does the influence of money pervert organ donation?

Deacon Barna, in A Christian Ending, writes that he has signed his donor card but is considering rescinding it. He offers two interrelated concerns. First, he claims that the transplant system is almost completely unregulated and that this leads to terrible things such as “transplant tourism” and organs being shipped abroad for profit. Second, he claims that everyone makes a profit from transplantation except the donors; he also complains that there is a market in organs and some people are being exploited. He writes that he now might permit donation of his organs only on the condition that his organs be used locally, and he encourages others to do the same.

I strongly agree with Deacon Barna’s general concerns that organ donation needs to be regulated and that the human body must not be commodified. However, his specific concerns are not valid when referring to the U.S. context,^[25] and to solid organ transplantation rather than tissue donation.^[26] I have served on the governing board of Mid-America Transplant, an organ procurement organization, or OPO. According to U.S. law, all OPOs must be non-profit entities. It is currently illegal to pay for organs in the U.S. (though this is legal in some nations such as Iran).^[27] Organ transplantation is a highly regulated enterprise. One regulation requires broad sharing of organs between states when feasible. Thus, any insistence that one’s organs only be used locally is not permissible by law—unless the individual becomes a living donor.

I think a further word on payments for organ donation is merited. Some Orthodox bioethicists have argued in support of permitting the sale of human organs, but their arguments are largely secular.^[28] The overwhelming opinion is that the sacred should never be treated like an object that is for sale, and that one cannot serve both God and mammon.^[29] The only justification for the violence done to the body at a time of mourning and Christian burial rituals is love of neighbor, the desire to be God’s instrument of healing. The National Organ Transplantation Act currently forbids payments for deceased donor organs, but if this changes Orthodox Christians may need to refuse payments.^[30] From a transplant community perspective, the primary purpose of payments is precisely to serve as an incentive, as a motivation for donation, and such a motive regarding the disposition of the human body is not appropriate.

There are many other questions about organ donation which I hope to explore elsewhere, including: Are some organs (e.g., the heart or testicles) too special to donate? Might our organs be received by someone who does not deserve them (e.g., a person with alcoholic cirrhosis)? Might granting permission for organ donation compromise the quality of care I receive in the event of serious injury? To be clear, I do not think these questions involve insurmountable concerns with organ donation, but people ask these questions, and they deserve informed answers. I plan to engage these questions in future work. Here I will circle back to the broad issue of organ donation through the lens of Orthodox Synods before offering concluding reflections.

Statements of Orthodox Synods

I have identified and reviewed synodal statements on organ donation from six jurisdictions: the Antiochian Orthodox Church; the Bulgarian Eastern Orthodox Archdiocese of USA, Canada, and Australia; the Greek Orthodox Church (GOA); the Orthodox Church of America (OCA); the Romanian Orthodox Church; and the Russian Orthodox Church.^[31] These statements range from one paragraph (e.g., OCA) to several pages in length (e.g., GOA). The statement of the Holy Synod of Antioch is fairly representative:

The Church accepts organ donation as an act of love, which donors suggest in complete freedom, provided that they do not hurt themselves. In cases of sudden death, the decision belongs to the deceased’s executor. The Church warns against the spirit of utilitarianism and commercialism which can exploit medical standards with the aim of removing parts of a living person in order to sell them to others, since it is not permissible in any circumstance for human parts to become a commodity.^[32]

All of the synodal statements teach that organ donation is permissible under specific conditions: It must be voluntary, a gesture of love or altruism, and free from financial payments. None of the synods speak of an obligation or duty to donate; they emphasize, rather, that a gesture of love requires freedom and voluntariness.^[33]

The Freedom and Responsibility of Conscience (syneidêsis)

The title of this paper asks whether organ donation is forbidden, permitted, or maybe even morally required. The answer is not simple. The synods that have addressed organ donation speak of the permissibility and goodness of donation but stop short of referring to a moral obligation. Orthodox Tradition emphasizes that donating organs after death must be voluntary.

But to borrow a phrase from Orthodox bioethicist Deacon Sampson Nash, not everything that is voluntary is optional.^[34] For those who have prayed about the decision and overcome concerns with organ donation, as I have at this time, granting permission for organ donation after death may in fact be morally required. Thus, the question about a moral obligation to donate organs is complex precisely because it cannot be answered in the same way, for all people, at all times. It is a mistake to think—as many ethicists do—that all obligations are general.^[35] We are all generally obliged to practice love of neighbor, to provide hospitality, and to offer healing to others; however, how we do this may look different for different Christians.