Article found on the web at: http://www.facs.org/education/ethics/childresslect.html

This article investigated the link between religious coping and the use of intensive life-prolonging care in patients dying of advanced cancer. Researchers found that positive religious coping was associated with more intensive life-prolonging medical care near the end of life. The study concludes that “clinicians should be attentive to religious methods of coping as they discuss prognosis and treatment options with terminally ill patients.” While the findings were amongst terminally ill cancer patients, the same outlook could be extended to patients dying of other causes, such as organ failure.

This article is a commentary on “A Definition of Irreversible Coma”, originally published in JAMA 1968;205(6):227-340 Commenting on the seminal 1968 paper defining criteria for determining brain death, Dr. Rosenberg emphasized the staying power of these criteria and explains new understandings of neurological states often confused with brain death, such as persistent vegetative state (PVS) and coma. The review proved a patient could have a dead brain in an otherwise healthy body and the identified this state as irreversible, both key steps in allowing for organ donation from these patients. Brain death is determined by the absence of all reflexes and normal brain electrical activity. PVS and coma patients, in contrast to brain dead patients, demonstrated neurological activity without visible wakefulness. These findings suggest that future research could elucidate what is happening in these states. Forty years after the Harvard paper, the concept of brain death and the road it paved to organ donation is strong; much work is left to be done to understand similar neurological states such as PVS and coma.

Chapter 10, page 233. Rabbi Yehiel Yitzchak Helavy, a scion of prominent Yemenite rabbis, was the Secretary General of the Office of the Chief Rabbi of Israel from 1969-1988. He shows how Jewish sources accept brain death as death and support organ donation. He has a video testimonial on the HODS video page.

This team of Israelis campaigns for a regulated system of organ sales and outlines its possible structure. Officially, organ sales are banned by the Ministry of Health today though it is not technically illegal. Unofficially, it is an “open secret” amongst the end stage renal disease community that kidneys can be bought and transplanted in developing countries with post-transplant follow-up provided by the Israeli government. Under the proposed system, kidney sales would be sanctioned by law and coordinated by Israel Transplant. Suitable donors would undergo the same workup already in place for cadaveric donors. Donor fee would be standardized by the Ministry of Health and paid post-operative by Israel Transplant, which would also be responsible for long-term donor follow-up. Any commercial transplantation outside this framework would be made illegal. Establishing a regulated system for organ sales could reduce overall cost of kidney disease patient management while ensuring better care for donors and recipients.

Dr. Ghods, an Iranian nephrologist, describes the history of kidney disease treatment in Iran. Owing to strong cultural and religious objection, no cadaveric organ donation program exists; living related donation is accepted. In 1988, with a growing waiting list, Iran began a controlled living unrelated donor (LURD) program. In this system, patients are encouraged to seek out a related donor. If no donor can be found, the patient is referred to a national LURD coordinating organization. After thorough recipient workup, a transplant is arranged from a matching donor who has also been thoroughly evaluated. After transplantation, the donor receives a “rewarding gift” from the government. The majority of recipients receive a similar gift from the donor’s family. These gifts, Dr. Ghods says, “have been limited to a range that the majority of patients of a poor socioeconomic class are able to afford.” By 1999, the program had been so successful that the waiting list was eliminated. Iran’s transplant and recipient survivor rates are high though they do not match Western standards. Dr. Ghods points out that Iran is a developing country whose medical infrastructure cannot compare to the developed world. The success of this program, combined with the scientific data available, make Iran’s living unrelated donor program a successful model of regulated organ sales warranting future investigation.

Written for the sixth yahrtzeit of J.J. Greenberg, Tuesday, the 8th of Tishrei (Oct. 7, 2008)