5785.1
Removing a Pacemaker from a Corpse for Reuse
Sh’eilah
I am writing to obtain clarification of an issue that has come up in my legal practice. It recently has been shown in studies that the use of refurbished pacemakers, extracted after death, for implantation to save the lives of indigent people in underserved populations is safe enough, and is now being implemented by the MHYH program. If a pacemaker is extracted from a body with the intention of using it to save a life, would that be permissible in Jewish law as understood by Reform Judaism, similar to an organ donation? (Jacqueline Brenner Berger, Esq., Cumming, GA)
T’shuvah
May we cut open a body after death to remove a life-sustaining medical device so that a physician can implant it in someone who needs it?
The short answer is that this very question was already asked of R. Eliezer Waldenberg of Jerusalem in 1979, and he replied in the affirmative.[1] We agree with his decision, and will refer to it in this responsum; but as the medical technology has changed and the health care systems of Israel and the United States are very different, we will address the question in more detail. A more detailed response is also useful since civil law may be involved here, and since the organization in question is not under Jewish auspices.
The shoelet references a charitable program called My Heart Your Heart (MHYH) established by physicians at the Frankel Cardiovascular Center at the University of Michigan.[2] MHYH invites funeral directors around the US to request authorization from next-of-kin to remove pacemakers from the deceased. With space provided at no cost by World Medical Relief, a Michigan-based charity whose mission is “to distribute surplus medical resources to those in need … without regard to race, color, gender, religion, nationality, or political beliefs,”[3] and the refurbishing provided gratis by a Connecticut firm whose business is refurbishing used medical devices, pacemakers are made available to patients in hospitals in several African and South American countries. MHYH’s 2024 informational video says this effort has provided pacemakers to about 175 needy people in locations with limited medical resources. The Frankel Cardiovascular Center is at present in communication with the US Food and Drug Administration about beginning clinical trials of the procedure in the US.
A pacemaker is a small electrical device that regulates the timing and sequence of a person’s heartbeat by sending electrical signals to the heart. Most pacemakers consist of a generator and a single or double lead.[4] The generator is a battery with a life of seven to ten years in a small hermetically sealed titanium capsule inserted subcutaneously under the clavicle. The leads are threaded through a nearby vein, positioned in proximity to the heart, and then they are connected to the generator. When not done in conjunction with a heart operation, this insertion procedure is generally done as outpatient surgery under local anesthesia and takes about one hour. Most generators today are about the diameter of a US half dollar coin and about three times as thick. Pacemakers cost between $8,000 and $15,000 or more, depending on the model complexity.[5]
Pacemakers are now standard care, covered by all insurance plans and by Medicare, but this does not mean that everyone can afford them. Medicare’s website provides an estimate of $1,625 for out-of-pocket costs but warns that this is not all-inclusive.[6] Medicaid covers pacemakers when medically necessary, but what that criterion means varies from state to state, as does the amount a person would have to pay out of pocket. High deductible insurance policies could leave people open to extremely high out-of-pocket costs.[7] Refurbished pacemakers could result in significant savings to individuals with insurance, and would also result in cost savings to Medicare and Medicaid programs, i.e., to taxpayers.
I. Halachah
A. Preserving life
We are commanded to preserve life.
How do we know that if one sees his fellow drowning in a river, or being dragged off by a wild beast, or beset by brigands, one is obligated to save him? This is the meaning of Do not stand by the blood of your fellow (Leviticus 19:16). But does this [obligation to save another’s life] come from this verse? Does it not come rather from that verse there (Deuteronomy 22:2), where we learn that [a person is obligated not merely to restore their fellow’s lost possessions but also their very life] from you shall give it back?[8]
While medical care is not specifically mentioned in these two verses, the halachah also relies on Exodus 21:19, which states that in the case of an individual who has injured another so that the other is bedridden, if the latter then gets up and walks outdoors upon a staff, the assailant shall go unpunished—except for paying for the idleness and the cure (v’rapo y’rapei, literally, he shall certainly heal him). Our tradition understands the words v’rapo y’rapei to mean that we are commanded to heal the sick through the practice of medicine.[9]
The major codes combine these verses into a broad endorsement of the role of the physician. Maimonides states that “[a] physician is obligated by law to heal the sick of Israel. This is explicitly included in Scripture. You shall give it back includes [“giving back” a person’s [“lost”] body. If one beheld another suffering a loss, and is able to save him, the one is obligated to do so, whether by means of physical action, financial outlay, or knowledge that one possesses.”[10] And in the Shulchan Aruch, R. Joseph Karo puts it thus: “The Torah has granted the physician permission to heal, and it is a religious duty which comes under the rule of saving an endangered life. If he withholds [treatment] he is regarded as one who sheds blood…”[11]
The limits on what constitutes acceptable medical treatments are extremely broad. “When a person becomes sick and is in danger of dying, if the physicians say that his cure involves transgressing a given Torah prohibition, [the physicians’ advice] should be followed. When there is a danger [to life], one may use any of the Torah prohibitions as a remedy, with the exception of the worship of false gods, forbidden sexual relations, and murder.”[12]
B. The cost of medical care
Our tradition values medical training because of its potential to save life. But if saving life is a mitzvah, then how can a physician be compensated? We do not compensate people for performing mitzvot. The answer is that we are not paying them for their medical expertise per se, which they are deploying for the sake of preserving life, but rather for their time and trouble. Furthermore, the halachah also forbids raising the price of medication unreasonably because it is in demand.[13] While reality has often been more complicated than that, nevertheless, the thrust of the halachah is clear. As R. Eleazar Fleckeles of Prague (1754–1826) wrote: “But if there is a poor person who has insufficient funds to pay a doctor, and the doctor does not want to go to him for free, the court compels the doctor to go and treat him, just as it compels the mohel to perform the b’rit milah for the son of a father who cannot afford to pay him.”[14]
C. Proper treatment of a corpse (k’vod hamet) and modern medicine
Out of respect for the dead (k’vod hamet), Jewish tradition prohibits disgraceful treatment of a corpse (nivul hamet); delaying the burial of a corpse (halanat hamet); and deriving benefit from a corpse (hanaah b’met). Nevertheless, given the overriding importance of preserving life, when faced with the real potential to save life by means of autopsies and transplants, modern rabbinic authorities generally agree that, when performed correctly, these are not acts of disrespect toward the deceased.
Nivul hamet: Nivul, meaning “disgrace, dishonor, degrade, humiliate,” is the term employed by the Talmud for what one should not do to a corpse. Like so much in the Talmud, however, the question of just what constitutes nivul is never systematically defined. As R. Jacob Lauterbach explained in 1925, there is no prohibition of autopsy per se in the Torah or in the rabbinic corpus,[15] only the prohibition of the disgraceful treatment of a corpse. In fact, the rabbis of the Talmud knew about autopsy and even suggested a circumstance under which it could be useful, i.e., to save a life.[16] Since the eighteenth century, eminent rabbinic authorities have recognized the medical value in autopsies, and have repeatedly ruled that if the knowledge obtained through an autopsy will preserve other lives, then autopsy is permitted. That many Jews and non-Jews today labor under the misconception that halachah prohibits autopsies is the result of late nineteenth and early twentieth century controversies over the procurement of corpses for medical study, to which some Orthodox authorities reacted with extreme vehemence and unjustified prohibitions.[17]
Mark Washofsky has written, “Reform Judaism permits autopsies so long as they are clearly performed for the purpose of increasing medical knowledge …. [A]utopsy is permitted in cases of pikuach nefesh, when the information to be gleaned through the procedure may help save another’s life.”[18] Reform Judaism, he notes, is more lenient than most Orthodox authorities in permitting autopsies even if the benefit of knowledge gained is not immediately life-saving, as in, for example, medical education, or even if the person who may benefit is not nearby.
… [I]n our day of rapid transportation and instantaneous communication, once-important considerations of time and place are now irrelevant. The entire world is “in our presence,” and we can be sure that there are patients who can benefit from the knowledge to be gained through autopsy. It is therefore unreasonable to place geographical or chronological boundaries upon the right of medical professionals to take action to preserve human life….
For similar considerations, Reform Judaism approves the donation of the organs of one’s body for the purpose of transplantation, either to save a life or heal a deficiency.[19] An individual may also donate his or her entire body to science, provided that the institution which is to receive the body is known to treat the body with respect and that, when the study is completed, the remains are buried or cremated.[20]
In short, the importance of preserving life cancels out the nivul done by performing an autopsy or a post-mortem transplant.
Halanat hamet: The obligation to bury our dead as soon as possible is derived from the Torah’s commandment not to leave the body of a criminal hanging overnight.[21] However, the halachah also stipulates that it is permissible to delay burial in order to bury the deceased properly and with honor (e.g., to procure shrouds or a coffin, arranging a proper eulogy for a distinguished person, waiting for the family to arrive).[22] The amount of time required to remove a pacemaker, however, is so minimal as to be insignificant.
Hanaah b’met: It is forbidden to derive benefit from a corpse. In addition to the body itself, all authorities agree that it is also forbidden to reuse items used for burial, such as shrouds, coffins, and material used to construct an above-ground tomb.[23] The Talmud, the Tur, and the Shulchan Aruch all state that this includes “ornaments” that are “attached” to the body. Isserles adds the clarification that it is forbidden to make use of a wig, for example, if it is actually attached to the deceased, and permitted if it is not; thus rings, he specifies, are permitted.[24] One may specify before death how to dispose of all these items, including those that are “attached.”[25]
The question of what can or cannot be reused gains depth and context from considering what follows it immediately in the Talmud and codes. We quote here the relevant passages from the Shulchḥan Aruch:
3) If his father and mother were throwing garments onto him [i.e., acting in their grief, intending these to buried with him], it is a mitzvah for others to rescue them, as long as they [the garments] have not actually touched the bier that will be buried with him. (Isserles: And the one who rescues them is obligated to keep them, for if he returns them to the parents and they again throw them on the bier [and they cannot be rescued] and they become forbidden, the one who rescued them must pay for them, since it is as if he had thrown them into a place of wild beasts or robbers.) But if the garments touched [the body of the deceased], they are forbidden, provided that the garments belonged to the one upon whom they are throwing them, and that they were thrown with the intent that they would be buried with him….
4) Anyone who throws excessive quantities of garments upon the dead is violating the prohibition against unnecessary wastefulness (bal tashchit).[26]
In other words, in determining what must be buried with the dead, what must not be buried, and what may or may not be buried, our sages also considered the obligation to avoid wastefulness.
Conclusions
To quote R. Waldenberg, “Because the question before us involves wasting a large sum, and also because it involves saving life, whether immediately or further into the future, it appears to me that there is room to be permissive.” We fully agree with him. As we have seen:
1. The practice of medicine: The imperative of saving or preserving life is far-reaching, and the ethical imperative of not denying medical care on the basis of ability to pay is integral to our tradition’s view of the practice of medicine.
Since R. Waldenberg wrote his responsum in 1979, the cost of pacemakers has come down enormously, and in developed countries such as the US and Canada their use has become routine rather than extraordinary. Nevertheless, given the state of the US healthcare system, we still need to worry about access to this potentially life-saving intervention. On some insurance plans, a pacemaker procedure would still require a high out-of-pocket expenditure. In a non-emergency situation, an individual might choose to gamble with their health rather than incur a budget-shattering expense. Or ER medical professionals treating an uninsured individual for some other reason might discover that the patient needs a pacemaker—but in a non-emergency situation, an uninsured patient will not receive one.[27] Additionally, reusing pacemakers would contribute at least a bit to bringing down the cost of health care for all.
2. Treatment of a body: We already permit autopsies and organ transplants to preserve life, deeming them higher priorities than the concern for “disgrace.” The time required to remove a pacemaker is minimal, and will not unduly delay burial. And we are not deriving benefit from the corpse, but rather from a separate valuable object that would simply go to waste if it were buried with the body.
For all these reasons, we find nothing objectionable here. Indeed, it is a commendable act, just like donating an organ.
3. Additional considerations: The University of Michigan’s Frankel Center MHYH Project reaches out to funeral directors across the US. They obtain the families’ permission and perform the brief procedure to remove the pacemaker, disconnecting it from its lead wires. That is, in fact, exactly what R. Waldenberg recommends. For MHYH it is simply that the leads cannot be reused. For R. Waldenberg and for us, the leads are attached to the body and must not be reused.
We note also that state regulations require pacemakers to be removed from bodies that are to be cremated, since burning them releases toxic pollutants into the atmosphere.[28] It is possible that green cemeteries may also require removal of pacemakers, since they do not decompose, or if they do, they will leak potentially toxic substances into the soil.
As an additional caution, R. Waldenberg suggests that a person should complete a form prior to death indicating their intent to have the pacemaker removed for reuse. This is in keeping with the halachic provision that a person’s wishes concerning the disposal of the effects on their person are to be heeded.[29] We believe that making a provision like this could be a valuable and meaningful gesture on the part of a dying person—or, indeed, well before their dying—but we wish to state that the individual’s consent is not a necessary precondition for retrieving a pacemaker after death.
CCAR Responsa Committee
Rabbi Joan S. Friedman, PhD, chair
Rabbi Carey Brown
Rabbi Phil Cohen, PhD
Rabbi Ben Gurin
Rabbi Audrey Korotkin, PhD
Rabbi Amy Scheinerman
Rabbi Micah Streiffer
Rabbi David Z. Vaisberg
Rabbi Michael Walden
Rabbi Dvora E. Weisberg, PhD
Rabbi Jeremy Weisblatt
[1] Eliezer Waldenberg, ShU”T Tzitz Eliezer XIV #83.
[2] The information in this paragraph is from the Frankel Cardiovascular Center’s website and linked informational videos: https://www.umcvc.org/conditions-treatments/my-heart-your-heart; https://www.youtube.com/watch?v=OgGjUI957VE; and https://www.youtube.com/watch?v=LhenitWwZvA, accessed January 21, 2025.
[3] https://www.worldmedicalrelief.org/about-us, accessed January 21, 2025.
[4] There are now also wireless/leadless pacemakers, tiny capsules that are implanted within the heart. These are not subject to retrieval for reuse. This and the remainder of the information in this paragraph are taken from Richard N. Fogoros, MD, “All About Pacemakers,” available on the Verywell Health website, updated September 25, 2024 (https://www.verywellhealth.com/pacemakers-what-you-should-know-1745231#:~:text=There%20are%20a%20few%20different%20types%20of%20pacemakers:).
[5] “How Much Does a Pacemaker Cost?” at The Pricer (https://www.thepricer.org/the-cost-of-a-pacemaker/).
[6] https://www.medicare.gov/procedure-price-lookup/cost/33208/, accessed February 12, 2025.
[7] “How Much Does a Pacemaker Cost with Medicare?” https://fairsquaremedicare.com/articles/how-much-does-a-pacemaker-cost-with-medicare, accessed February 12, 2025.
[8] BT Sanhedrin 73a. See also ShA ḤM 426:1.
[9] BT B’rachot 60a; BT Bava Kama 85a; Shulchan Aruch YD 336:1.
[10] Commentary to Mishnah N’darim 4:4.
[11] ShA YD 336:1.
[12] Yad H. Yesodei Torah 5:6. See also BT P’sachim 25a.
[13] ShA YD 336:2-3 and commentaries ad loc.
[14] Quoted in Waldenberg, Tzitz Eliezer Part XIV #27. Waldenberg actually goes on to cite an assertion by 18th century authority R. Jacob Emden that “… [I]f it is not possible in any way to persuade the physician to treat him for free, because he is ignoring us, then it is permitted by law to deceive him and to say that they will pay him, and then afterward not to pay.”
[15] American Reform Responsa #82: Autopsy (https://www.ccarnet.org/ccar-responsa/arr-278-283/).
[16] BT Chulin 11b. In the case of a person accused of capital murder, they may open the body of the victim to ascertain if the victim was a t’reifah, a terminally ill person who would have died within the year, in which case the killer would not be liable to execution. Thus, if the purpose is to save a life, the “disgrace” is allowed. See also BT Bava Batra 154a and 155a.
[17] Contemporary Reform Responsa #49: Bequeathing Parts of the Body (https://www.ccarnet.org/ccar-responsa/corr-216-223/).
[18] R. Mark Washofsky, Jewish Living: A Guide to Contemporary Reform Practice (NY: UAHC Press, 2000), 188–189 and notes ad loc. See also American Reform Responsa #84: Transplanting the Eyes of Deceased Persons (https://www.ccarnet.org/ccar-responsa/arr-287-288/).
[19] We have strong reservations about some situations involving harvesting organs close to death, but those issues are not relevant to the question of retrieving a pacemaker from someone who has been declared dead and is being prepared for burial. See Reform Responsa for the 21st Century, Vol. II, 5763.3: Hastening the Death of a Potential Organ Donor (https://www.ccarnet.org/ccar-responsa/nyp-no-5763-3/).
[20] Washofsky, Jewish Living, 188–189. The reference here to cremation is not an endorsement of the practice, which is contrary to traditional ideals of k’vod hamet, but an acknowledgement of the fact that since 1893 the position of the Central Conference of American Rabbis has been that Reform rabbis do not refuse to officiate at a Jewish funeral when the deceased has opted for cremation. See American Reform Responsa #100: Cremation from a Jewish Standpoint (https://www.ccarnet.org/ccar-responsa/arr-341-348/).
[21] Deuternomy 21:23; BT Sanhedrin 46a; Mishneh Torah, Avel 12:1.
[22] BT Sanhedrin 46a; Tur ShA YD 357:1.
[23] BT Avodah Zarah 29b; BT Sanhedrin 47b–48a. To “derive benefit” means either to have the use of an object or to sell it for monetary benefit.
[24] Maimonides alone explicitly permits the use of a corpse’s hair, since “it is not his body.” Mishneh Torah, Avel 14:21.
[25] Tur YD 349; ShA YD 349:2.
[26] ShA YD 349:2-3. Bal tashchit, the prohibition of unnecessary wastefulness in all things, is derived from Deuteronomy 20:19–20, which prohibits cutting down fruit trees for use in war. See also BT S’machot 48b and Mishneh Torah, Avel 14:24.
[27] Thanks to Bryan Hecht, MD, for clarifying this.
[28] See n. 1.
[29] ShA YD 349:2.