Organ donation presents a conflict for many Buddhists. On the one hand, we strive to attain the bodhisattva ideal of compassionate action whenever possible. Nine people die in this country every day waiting in vain for donors. On the other hand, according to some Buddhist teachings, death comes when the consciousness leaves the body, not with the last breath, and it is generally believed that the circumstances of clinical death and the period following it, before the consciousness is released, are critical in helping to determine one’s rebirth. According to that view, it is best not to cut into the body for three days following clinical death or risk disturbing the process.
Yet in order to transplant an organ effectively, the body must be cut into quickly following the last breath—the sooner the better—thus violently disturbing the natural process of consciousness merging back into formlessness. The request by many Buddhists that their bodies not be tampered with for three days following clinical death—even though clinical death is itself an imprecise term—disqualifies them from donating organs and tissue, since those parts of the body must be harvested sooner than that.
Chan master Sheng-Yen and Zen master Tangen Harada Roshi have taught that even though the process of donation might be disturbing to the donor, if the donor’s practice and concentration are steady, and his or her desire to help others is strong, then donating would fulfill the aspiration to help others. People so inclined react strongly to the plight of the tens of thousands of patients waiting for donors.
Another view is that since we don’t know how we will react to the process of donation during this crucial transition, it is better to avoid it. People inclined to this view often emphasize the troubling commercial aspects of donation, the high costs, and the seemingly arbitrary priorities of allocation. They may also be concerned that overeagerness could lead to organs being removed when a patient might still be revived, although I am unaware of any such case.
Brain death raises further questions. The vast majority of organ donors are brain-dead patients; the body is kept on life support, while social and medical arrangements are made for the donation. A young, healthy person who suffers a fatal head injury is a paradigmatic donor. Yet brain death is also an imprecise term, since the brain can show some activity even hours after the breath has stopped. We don’t fully understand the relationship between consciousness and brain death.
The difficulty this presents is demonstrated by the fact that Japan legally recognized the concept of brain death only this April. Previously, transplants were extremely difficult to obtain in Japan. Until we have more knowledge or collective wisdom about this issue, people will have to decide for themselves through belief and intuition. Adopting a view of brain death qua death would provide a way for Buddhists to become donors while maintaining the three-day transition period. Yet, it is just as easy to speculate that the activity of the brain following the last breath is related to the activity of consciousness.
For some, another approach may help navigate the murky waters of organ donation and still provide some benefit to others. If one waited just short of twenty-four hours after cardiac death, one could still donate bone and other vital tissue, though not organs. Some Buddhists may consider the shorter waiting period sufficient and could become donors as a result. If they are willing to risk any hardship, as Sheng-Yen suggests, also donating one’s body for medical research can be accomplished after accommodating the three-day waiting period. Procedures such as embalming, autopsy, or cremation can likewise be postponed if the body is refrigerated.
Finally, there are three other ways to become a donor while one is alive and well: kidney, marrow, and blood donation. Everyone knows about donating blood at the Red Cross. Fewer are aware that they can also sign up for the Marrow Donor Program simply by giving blood, and possibly help someone by later donating marrow. A healthy person could also donate one of his or her kidneys.
Once we make a decision, we need to ensure it will be carried out. We do this as much to relieve our families of hard choices as we do to see our wishes fulfilled. Advance medical directives are the documents best suited to this end. Living wills are the oldest and best-known directives, but also the most limited. They apply only to terminal conditions, and do not address donations.
More effective and flexible is the appointment of a health-care agent (or surrogate, or proxy). This person is legally recognized in every state as the one who will speak for you when you can no longer speak for yourself. You need to empower this person through a proper legal document in a form that is familiar to the health care providers. You should provide as much specific guidance as you can, as well as a sense of your attitudes. Because it is impossible to address every issue beforehand, the discretion and judgment of the agent is essential. Although most states have adopted the Uniform Organ Donation Act, which legally requires that a directive for organ donation be followed, in practice it is the voice of those still living that controls the decision.
Inexpensive forms for appointment of a health-care agent are available from Choice in Dying (800-989-9455) and the World Federation of Right to Die Societies, in England (44-181-574-3775).
The primary issues about donations are listed below. Reflect on them, and communicate your decisions to a health care proxy in writing:
1. I make a gift of any anatomical part of my body (allows donation of organs, bone, tissue, corneas).
2. I make a gift of any anatomical part, but not sooner than one day after cardiac death (allows bone and some tissues, but not organs).
3. I make a gift of my body for research only, but not sooner than three days after cardiac death (body is refrigerated in the meantime).
4. I make a gift of any anatomical part, but not sooner than three days after brain death (allows organs, bone, tissue, corneas).
5. An autopsy may be performed if necessary, but not sooner than three days after cardiac death (body is refrigerated in the meantime).
6. I may be embalmed, but not sooner than three days after cardiac death (body is refrigerated in the meantime).
7. I want to be cremated, but not sooner than three days after cardiac death (body is refrigerated in the meantime).
8. I want to be buried, but not sooner than three days after cardiac death (body is refrigerated or sealed in the coffin in the meantime).
Practitioners must personally navigate the intersection of these timeless issues and modern technologies. A longtime Zen practitioner, I have chosen to be a future organ and tissue donor, as well as a current marrow and blood donor. However, were I to be a guardian or parent, I would not allow my ward or children to donate before they could make a personal, informed choice. I judge myself ready to accept any added problems caused by this decision, but I would not demand that of others.
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