An Interpretive Approach to Religious Ambiguities around Medical Innovations: The Spanish Catholic Church on Organ Donation and Transplantation (1954–2014)

Abstract

How do institutionalized religions solve moral ambiguities around controversial medical innovations and public health issues? Most religions have moral guidelines about what can and cannot be done to people’s bodies, but these guidelines are not always straightforward and, when faced with certain scientific advances, can come into contradiction with other doctrinal principles. I address this theoretical puzzle through the empirical case of the Spanish Catholic Church’s discourse on organ donation and transplantation during the second half of the twentieth century. Drawing on an interpretive analysis of official statements by the Spanish Catholic Church, and of the media coverage of the religious debate over organ donation and transplantation in Spain from 1954 onwards, I show that the first experiments in organ transplantation faced the Church with a contradiction between its altruistic teachings and its beliefs in the sacredness of human life. Faced with an interpretive dilemma, the Church produced a context-specific version of its official doctrine friendly to organ donation and transplantation. It did so by activating its altruistic elements and suppressing sacralized meanings of the body, thus aligning organ donation with Catholic values of generosity and fraternal love. My study theorizes this moral alignment as a semantic overlap realized through historically situated institutional discourse. Additionally, it incorporates 24 primary and secondary sources on comparative cases to propose three facilitating factors that enabled and encouraged the Spanish Catholic Church to embrace a controversial medical practice.

Introduction

This article examines how institutionalized religions solve moral ambiguities around controversial medical innovations and public health issues. Most literature on these topics considers religion an individual-level independent variable that directly impacts people’s attitudes, behaviors, and decisions, an approach to understanding religion that sociologists have criticized before (Ammerman 2014; Edgell 2012). Following these authors, I treat religions as complex and fragmentary belief systems that hold multiple—and sometimes contradictory—moral principles of evaluation (Baggett 2006; Dillon 1996a, 1996b). These contradictions, which present challenges for interpretation and evaluation, do not sort themselves out in the abstract but rather in concrete attempts to resolve specific problems (McDonnell et al. 2017).

Building on this perspective, I address the case of the Spanish Catholic Church’s support for organ donation and transplantation during the second half of the twentieth century. The Spanish Catholic Church has historically expressed little reservations about organ transplantation; it frequently encourages Catholics to donate organs, invoking Christian generosity and fraternal love (Monseñores Álvaréz and Cases 2009; Monseñor Asenjo 2014; Monseñor Martínez Sistach 2008).

However, the Catholic doctrine provides arguments to both support and reject organ donation and transplantation. Catholicism promotes altruistic behavior, encourages believers to give without expecting compensation, and praises generosity and self-sacrifice. Such principles overlap with the “gift of life” paradigm that dominates discourses on organ donation and that defines it as an intrinsically altruistic act (Healy 2004a; Vernale and Packard 1990). But certain elements in the Catholic doctrine are incompatible with organ procurement. Literal interpretations of the Resurrection dogma—part of the Catholic Eschatological doctrine—imply that dead bodies must be buried whole, so that they can resurrect in flesh. Additionally, Catholicism defends the sacredness of human life, which can raise questions about the medical definition of brain death (Brown 2007; Byrne 1999; Furton 2002).

How did the Spanish Catholic Church negotiate this contradiction? My analysis of official statements by the Spanish Catholic Church and of the media coverage of the religious debate over organ donation and transplantation shows that the first experiments in organ transplantation confronted the Spanish Catholic Church with an interpretive dilemma. As one of Spain’s highest moral authorities, the Spanish Catholic Church was expected to provide non-specialists with a moral framework to evaluate this new medical practice (Ecklund et al. 2017), but organ transplantation called forth a contradiction between Catholicism’s altruistic values and its beliefs in the sacredness of the human life and body. Furthermore, it did so at a moment when the Spanish Catholic Church’s legitimacy was declining. Changes in the Church’s position within the Francoist regime, and Spain’s rapid secularization during the late 1960s and 70s (Pérez-Agote 2012), put the Spanish Catholic Church in a delicate predicament. Supporting organ donation and transplantation allowed the Spanish Catholic Church to recast itself as a modern institution compatible with a democratic regime, but required extensive interpretive work to produce a historically and contextually specific version (Edgell 2012, 251) of the Catholic doctrine favorable to organ transplantation by activating some of its normative evaluations and suppressing others.

To uncover and situate the processes of meaning-making that underpin the Spanish Catholic Church’s support for organ donation and transplantation, I translate religious principles of evaluation into the vocabularies that they deploy. By doing so, I employ an interpretive, language-based approach to concepts like elective affinity (Howe 1978; Swedberg and Agevall 2016; Weber 2003) and frame alignment (Benford and Snow 2000; Snow et al. 1986), conceptualizing them as overlaps between vocabularies that make certain combinations of beliefs and practices compatible. To facilitate my analysis, I group similar elements of the Catholic doctrine—and the evaluative principles and the vocabularies that they invoke—in “packages” (Beckett 1996; Gamson and Lasch 1983; Gamson and Modigliani 1989; Garrison 1988) and assess how they relate to organ donation and transplantation. My findings show that, by invoking an altruistic interpretive package centered around principles of altruism and generosity, and deactivating a sacralized body interpretive package centered around the sacredness of the human life and body, the Spanish Catholic Church materialized an “elective affinity” (Swedberg and Agevall 2016; Weber 2003) and counteracted a potential “negative affinity” (Löwy 2006) between Catholicism and organ procurement, aligning organ donation with Catholic values of generosity and fraternal love.

To move beyond the Spanish case, I rely on 24 primary and secondary sources on comparative cases to propose three facilitating factors that enabled and encouraged the Spanish Catholic Church to show an early and continued support for organ donation and transplantation despite the moral and religious controversies that surrounded this medical practice. First, the very content of religions’ theological and moral principles places limits for reinterpretation. In other words, some religious principles are easier to reinterpret in a way that supports a certain medical innovation, while others resist such reinterpretations. Second, religious institutions and authorities vary in their degree of unity and homogeneity. While some religious groups can provide believers with clear moral guidelines, others face intradenominational disagreements between different approaches, and sometimes leave moral dilemmas to the individual. Finally, the larger sociopolitical context—specifically, the relationship between religion, State, and public—provides background conditions that shape how religious institutions approach controversial medical innovations.

Empirically tracing this process exposes cultural dynamics that, operating at the level of meaning (Kane 1991), define universes of possible institutional discursive action. Simultaneously, it shows how historical contexts shape institution’s discursive choices, making visible the cultural work that institutionalized religions do to position themselves on controversial topics while balancing cultural constrains, historical conditions, and their own interests.

My findings make contributions to several disciplinary literatures. For cultural sociologists, my article builds on an interpretive approach to the relationship between beliefs, discourses and practices that allows for diverse research strategies and approaches to the study of culture. For medical sociologists, it adds to the well-established body of literature on the cultural legitimation of medical innovations (Blume 2013; Joyce 2005), in this case via religious arguments. For public health scholars, it offers an alternative account of the relationship between religion and organ donation and transplantation that illuminates the challenges that institutionalized religions face to position themselves in the face of new, controversial scientific discoveries.

An Interpretive Perspective on Religion and Organ Transplantation: From Cultural Logics to Discursive Contexts

Public health scholars have shown keen interest in whether religious beliefs encourage or prevent people from becoming organ donors. Their studies have yielded contradictory results. While most find that survey respondents mention religious reasons to refuse to donate organs (Berzelak et al. 2019; Hasan et al. 2019; Irving et al. 2012; Siminoff et al. 2020; Tontus 2020; Umair et al. 2020), others find that respondents sometimes consider their religious feelings a reason to donate organs (Demırkiran et al. 2019; de Groot et al. 2012; Irving et al. 2012).

A cultural perspective on the relationship between religion and organ transplantation can solve two epistemological shortcomings that may explain these inconsistent results: First, most of these studies operationalize religion as an isolated, individual-level variable with a direct causal effect on people’s likelihood to become organ donors, a common practice in the study of religion’s role in people’s decision-making that other sociologists have criticized before (Ammerman 2014; Edgell 2012). Second, many of these studies work with an abstract, ahistorical notion of religion—or “religiousness”—that strips it from its local forms and sociohistorical contexts (Santayana 2015). Conceptualizing religions as sets of institutionalized and publicly available discourses (Ammerman 2005, 2014) may be empirically less straightforward, but it’s better suited to analyze the religious and moral ambiguities that surround organ donation and transplantation and other, potentially controversial, medical innovations and public health issues.

Of the variety of models that sociologists have produced to link beliefs and practices, I build on the interpretive tradition that conceptualizes complex, abstract principles of evaluation in terms of the vocabularies and symbolic resources that they deploy to assess overlaps between meanings. As early as in The Protestant Ethic and the Spirit of Capitalism, Weber uses the term “elective affinity” to explain how Protestantism favored the development of a capitalist work ethic (Weber 2003). He defined elective affinity as the mutual attraction of elements, but he used the concept informally (Swedberg and Agevall 2016). Inferring a definition of the term from Weber’s intellectual environment, Howe (1978) proposes a semantic interpretation. He defines elective affinity as a “property of concepts that have features in common with other concepts” (Howe 1978, 376), and suggests conceptualizing these commonalities in terms of affinities in language (Howe 1978, 179). Overlapping vocabularies define universes of possible action, making certain combinations of beliefs and practices compatible or incompatible, and generating both affinities and negative affinities (Löwy 2006).

More recently, the framing approach made a concerted effort to translate ideological positions into vocabularies, symbolic resources, and meanings. Following the work of Erving Goffman, this approach defines collective action frames as “schemata of interpretation” (Goffman cited in Benford and Snow 2000, 614) that make events meaningful. For example, media and public opinion scholars have relied on frames and framing as tools to understand how cultural discourses -or texts- influence people’s consciousness (Entman 1993; Garrison 1988). Analytically, this perspective identifies the “linguistic and symbolic resources that make sense of and give meaning to one or more aspects of social issues” (Beckett 1996, 60) and aggregates them in clusters or “packages” (Gamson and Lasch 1983; Gamson and Modigliani 1989; Garrison 1988). In addition, social movements scholars have applied a “framing perspective” to understand constituents’ mobilization by highlighting movement actors’ interpretive work and attending to its processual character (Benford and Snow 2000). These scholars use the term “frame alignment” to refer to the efforts by movement actors to link “individual and social movement interpretive orientations, such that some set of individual interests, values, and beliefs and SMO [social movement organization] activities, goals, and ideology are congruent and complementary” (Snow et al. 1986, 464).

The combination of Howe’s reinterpretation of Weber’s elective affinities, and the notion of alignment proposed by the framing perspective, is especially useful for the case at hand, given the overlapping moral and sociopolitical goals that I argue the Spanish Catholic Church was pursuing in its attempt to legitimize and support organ transfer. On one hand, elective affinity, when approached from an interpretive perspective, captures the extent to which there is an overlap in language, vocabulary, and meaning between two distinct spheres of social life. On the other hand, frame alignment captures the interpretive work performed by individual or collective actors to create that overlap in language, vocabulary, and meaning.

The interpretive processes that I analyze here were oriented, primarily, to generating a compatibility—this is, an affinity—between two different areas of social life, the Catholic doctrine and the dominant paradigms of organ donation, procurement, and transplantation, something I argue was achieved by creating an overlap in vocabularies. In addition, as transplantation became an accepted therapeutic option and the transplant organ shortage became a pressing social problem, creating this overlap also involved mobilizing the Church’s constituents to donate their organs. This, in turn, provided the Spanish Catholic Church with considerable secondary gains, for it gave it the opportunity to recast itself as a modern, democratic actor invested in Spain’s scientific and social development.

Beyond the particularities of the empirical case at hand, dissecting abstract principles of evaluation into the vocabularies they deploy has several advantages. First, it makes cultural dynamics empirically traceable. Incommensurability is a salient issue in the sociology of culture (Ghaziani 2017), which highlights the importance of anchoring cultural dynamics in observable units of analysis.

Second, cultural dynamics, while operating with a degree of autonomy, depend on institutional discursive action that is embedded in sociohistorical contexts (Kane 1991). Tracing cultural dynamics on concrete texts makes it possible to situate said dynamics in their sociocultural environments and link them to broader historical processes that are “largely beyond actors’ direct control” (Diani 1996, 1055) and that affect the potential success of a particular framing. Institutional discourses are embedded in discursive fields, which contain the symbolic resources for discourse elaboration and reflect a pattern of relations between the actors that participate in them (Snow 2008). In this case, the Spanish Catholic Church’s discourse on organ transfer plays against the backdrop of the changing relationship between the Church itself, the Spanish state, and the Spanish public during the second half of the twentieth century. Changes in the cultural preeminence of the Spanish Catholic Church, then, provide the discursive context in which its public discourse on organ donation and transplantation unfolds.

In summary, this approach to the relationship between religion and organ procurement accounts, on one hand, for the internal logics of religions as symbolic systems that affect public life (Alexander 1990; Ammerman 2005, 2014; Geertz 1973). On the other hand, it situates those logics within social, political, and historical contexts (Alexander and Smith 2006; Kane 1991), explaining the role of religious institutions as intentional actors that “constrain the emergence and impact of certain cultural meanings and, at the same time, allow others to become enormously significant” (Baggett 2006, 297).

Data and Methods

I analyzed 80 primary sources (see Appendix 1). They include official statements about organ donation and transplantation by Spanish Catholic authorities, newspaper articles covering the religious debate on organ procurement on three leading national newspapers (ABC, La Vanguardia, and Ya), from 1954 until 2014, and Dominican priest José Todoli’s book Ética de los Trasplantes (“The Ethics of Transplantation”), which received some media attention at the time of its publication. I included the press coverage of the debate in my analysis because it reflects the role of Spanish Catholic authorities -theologians, moralists, bishops, etc.- in the public debate around organ procurement. Additionally, Catholic authorities’ appearances in the press were central to the Church’s communicative strategy to influence public opinion, given that, for lay people, the press and other media was their main point of access to theological debates about organ transfer.

The newspapers I selected do not represent a comprehensive picture of Spain’s media ecology. However, the three of them were leading opinion centers around the time the public discussion about organ transplantation was at its peak. Besides, the newspapers’ conservative editorial views make them more likely to report on the Catholic Church’s opinions. During the Francoist dictatorship, these publications were friendly to the regime without being part of the state-sponsored media. After Franco’s death, La Vanguardia moved towards a pro-catalan perspective, but retained its conservative character. Ya belonged to Editorial Católica, a publishing company property of the Spanish Catholic Church. Although in 1988 the Spanish Episcopal Conference sold Ya to another publishing group, the newspaper remained primarily a Catholic outlet. Articles from both ABC and La Vanguardia were available through their online archives. Articles from Ya were available at the Spanish National Library in Madrid, and only from 1970 until 1996 (when the newspaper closed down).

I analyzed my data through multiple rounds of close reading. In the first stage, I inductively classified the arguments that Catholic authorities invoked in the public discussion about religion and organ transplantation that took place in Spain since the 1950s, and organized them in two “packages” (Altomonte 2020; Beckett 1996; Gamson and Lasch 1983; Gamson and Modigliani 1989), summarized in Table 1. Each package is anchored in a specific set of doctrinal sources, invokes a specific set of associated principles of evaluation, deploys a specific vocabulary, and implies a moral position towards organ transfer. The first package, which I call sacralized body, clusters around questions about the nature of life and death and about the divine ownership over the human body. The second package, which I call altruistic, clusters around Catholic social ethics and notions of generosity, self-sacrifice and fraternal love. Although other moral and doctrinal arguments appear in the discussion, their presence is not as salient compared to the ones highlighted here.

Table 1 Sacralized body and altruistic interpretive packages. Doctrinal sources, associated principles of moral evaluation, vocabulary examples, and moral positions towards organ transplantation

Each package overlaps and clashes, respectively, with the two dominant cultural paradigms of organ donation (Moloney and Walker 2000, 2002). The altruistic package overlaps with the “gift of life” paradigm that, as has been thoroughly researched, dominates the public discourse about organ donation in Western and Westernized societies and highlights its altruistic nature (Galasiński and Sque 2016; Gerrand 1994; Healy 2004b, 2004a, 2006; Joralemon 1995; Lock 1999, 2002; Siminoff and Chillag 1999). The sacralized body package clashes with representations of the body as a machine made of interchangeable parts, of the cadaver as “waste”, and of organ extraction as “harvesting” that other scholars have identified as part of the organ procurement imaginary (Hogle 1999; Lock 2002; Sharp 2006). The intersection between the gift of life paradigm and the altruistic package creates points of affinity (Howe 1978) between Catholic beliefs and organ procurement. Meanwhile, the clash between the sacralized body package and medical resignifications of the body generates a moral incompatibility -a “negative affinity” (Löwy 2006)- between Catholicism and organ transplantation. Aligning organ procurement and Catholicism required Catholic leaders to do extensive cultural work to neutralize the sacralized body package and to activate the altruistic one (Fig. 1).

Fig. 1

Elective and negative affinities between cultural paradigms of organ donation and transplantation and altruistic and sacralized body interpretive packages

In the next analytical stage, and after observing a chronological evolution in the salience of each package, I analyzed the data interpretively, producing a “thick description” (Geertz 1973) of the transformations in the Spanish Catholic’s Church discourse on organ procurement. This approach, which combines the analytical leverage of classification and the attention to texture and detail of interpretive analysis, is the most appropriate one for the type and amount of data in this study. It allows me to hermeneutically reconstruct the religious debate on organ donation and transplantation in Spain since the 1950s and to situate it in its sociohistorical context (Alexander and Smith 2006).

Finally, and for comparative purposes, I examined 24 primary and secondary sources exploring how other religious denominations have reacted to and interpreted organ donation and transplantation to provide comparative cases and build a more general argument about religious interpretations of medical innovations.

Findings

Interest in the religious debate on organ donation and transplantation spikes at moments of rapid change, like the first heart transplant in 1967 and the subsequent experiments in solid organ transplantation, the approval of the Spanish transplantation law in 1979, and the discovery of cyclosporine in the early 80 s and the consequent shortage of transplant organs. In “unsettled times” (Swidler 1986), the Spanish Catholic Church worked to elucidate the moral character of organ transplantation, and to establish normative guidelines for action for its followers.

The religious conversation around organ procurement declined since the late eighties and early nineties. By the year 2000, the question was settled. Although the Spanish Catholic Church has continued to show public support for organ donation (see, for example, Monseñores Álvaréz and Cases 2009; Monseñor Asenjo 2014; Monseñor Martínez Sistach 2008), by then organ procurement was already a routine medical and social practice and the Church had clarified its position. Additionally, the creation of the Organización Nacional de Trasplantes (“National Organization for Transplants”)—the state-run institution that manages organ procurement in Spain—in 1989 imposed a higher degree of institutional control over the promotion of organ donation and transplantation. Finally, in the next few years organ donation rates in Spain soared, and Spain became the global leader in organ donation in 1992, making the shortage of transplant organs less urgent than it had been a few years before.

In the next few pages, I present my analysis of the interpretive work that the Spanish Catholic Church did to align organ donation with the Catholic doctrine. I show that moral negotiations of sacralized notions of the body dominate the debate in the 1950s and 1960s. As organ transplantation becomes a routine medical practice and transplant organ shortages emerge as a social problem, the debate evolves towards an open dominance of the altruistic package, and an open rejection of the sacralized body package as “unscientific barriers”, “allegedly religious prejudices” or “pseudo religious atavisms”. Since the 1970s, the focus shifted to the promotion of organ donation as a charitable act (Table 2).

Table 2 Summary of changes in the religious debate around organ transplantation in the Spanish national press

Desacralizing the Body in Times of Medical Discovery

During the 1950s and 1960s, the religious debate about organ donation and transplantation centers around desacralizing the body. In these two decades, the Spanish Catholic Church worked on deactivating the sacralized body package, questioning or at least limiting its validity. This includes questioning the religious rights of cadavers, limiting the applicability of the Sixth Commandment, and accepting a separation between body and spirit—and between science and Church—that makes medical definitions of brain death acceptable. Although the altruistic package is present, the charitable nature of organ donation is not the core of the conversation.

This dilemma appears in my data for the first time in 1956, when Father Gnocchi—an Italian Catholic priest famous for his charity work—donated his corneas after his death (Cortés-Cavanillas 1956a; Efe 1956a; Moriones 1956). The Italian law prohibited cadaveric organ donation at the time. Father Gnocchi's illegal act pressured the Vatican to clarify the Catholic Church’s position. An ABC article published March 9^th, 1956, explains that the Pope would have to choose between a strict interpretation of St. Thomas of Aquinas’ writings, which mandates that only God can dispose of the person’s body, and a moderate position claiming that St. Thomas’ dogma only applies to living individuals, not to cadavers (Cortés-Cavanillas 1956b). The article itself suggests that the Vatican should opt for the more moderate position, describing cornea donation and transplantation as “a highly valuable social work, benevolent under God’s and society’s eyes, because it constitutes one of the most sublime examples of Christian Charity”. Implied is the idea that sacralized notions of the body hinder a “sublime” form of generosity, and that the possibility of exercising charity through organ donation renders them outdated.

Although its altruistic character appears as an argument for organ donation, the Vatican’s dilemma is framed as a choice between a strict and a moderate approach to St. Thomas’ dogma and to the sacred character of the body. On May 15^th, 1956, both ABC and La Vanguardia (Efe 1956b, 1956c) published Pope Pious XII’s statement, where he questions the religious rights of the cadaver and proclaims that, for Catholicism, “there is no religious obstacle that impedes transplanting a cadaver’s cornea into the eye of a patient” because “a cadaver is not, strictly, a subject of rights […] Organs do not constitute goods for the cadaver, because the cadaver does not need them”. This utilitarian argument dismisses St. Thomas’ dogma, and questions literal interpretation of the Catholic Eschatological doctrine, specifically of bodily resurrection.

In Spain, theologians and members of the Catholic Church took interest in the debate, but because Spain lacked the technical and human resources to perform transplants, it soon died down. The question came back to the public interest almost ten years later, as cornea and kidney transplants became a reality in Spain and elsewhere. On April 13^th, 1966, for example, ABC published a review of Jesuit doctor and priest Thomas J. O’Donnell’s book, Medical Ethics (P. C. 1966). The review praises how O’Donnell applies a modern reading of the Code of Canon Law to current practices such as organ donation. It explains that voluntary mutilation, prohibited by the Sixth Commandment (“thou shall not kill”), does not include voluntary organ donation. This exception limits the applicability of one of the most important components of the Catholic doctrine, smoothing the path for future discussions about brain death.

Dr. Christian Barnard’s first heart transplant in 1967 generated a new spike of interest in organ transplantation. On December 7^th, 1967, ABC echoed an article published in L’Osservatore Romano -the Vatican City State’ daily newspaper- reflecting on the relationship between the body and the spirit: “To which extent -the author ponders- is the fusion of soul and body indispensable? It would be better to say that the human being is spiritual, and that bodily organs are physically part of us, but they are not us” (Efe 1967). Embracing the cartesian divide between body and spirit signals a transit between sacralized and medicalized notions of the body that will become important to establish a definition of brain death as death.

The distinction between body and spirit, and between religion and science is even clearer Father Antonio Arza’s—Chair of Canon Law at the University of Deusto, in Navarre (Spain)- statement published in La Vanguardia on December 8^th, 1967 (La Vanguardia 1967). Father Arza claims that it is admissible for Catholics to give non-vital organs, like a kidney or a cornea, in life. He adds that donation of vital organs is legitimate only if the donor is dead, but that it pertains to physicians to determine what constitute death. The morality of cadaveric donation, then, rests on physicians having the adequate scientific tools to determine death, not primarily on religious principles.

The debate remained active despite these efforts to secularize the body. For example, on May 22^nd, 1968, ABC reports on a Symposium on organ transplantation held in Madrid during that week, where Father Gonzalo Higuera and theologian Narciso Tibau Durán insisted that higher moral norms and laws, not science for its own sake, must govern organ transplantation (ABC 1968b). Father Tibau also mentions that the results of organ transplantation contribute to determine their morality. Given the mixed results of organ—especially heart—transplants in the following months, this will become a central point of discussion. While transplants as a viable therapeutic option with a certain guarantee of success are morally acceptable, transplants as human experiments are not. This is a much more cautious position than the ones presented before, as it still considers sacralized notions of the body as viable tools to evaluate the moral character of organ transplantation.

This lingering ambiguity is particularly visible in Dominican Priest José Todoli’s book Ética de los Trasplantes (“Transplantation Ethics”), published in the Spring of 1968 and subject of some debate in the upcoming months (ABC 1968d; Fernández de la Mora 1968:; La Vanguardia 1968b; Ponce 1968; Todoli 1968). Father Todoli, who had studied Saint Thomas’ dogma in detail, insists that the Catholic Church no longer considers organ donation a form of mutilation, because the “principle of solidarity” overcomes the “principle of self-preservation” and justifies donating an organ to save someone else’s life. This applies to double organs, and to vital organs when the donor is dead. According to Father Todoli, however, terminal illness and brain death do not equate to death, since doctors have the moral mandate to prolong life as much as they can. He claims that only cardiac death constitutes death. His conservative views on the moral nature of life and death contrast with his claim that organs should be considered social goods, and with his support for opt-out systems.¹

Although ambiguities remained unresolved for a few years, the Spanish Catholic Church progressively embraced a position favorable to organ transplantation. In the summer of 1969, Madrid hosted the first Global Conference on Organ Transplantation (ABC 1969a; 1969b, 1969c, 1969d, 1969e; La Vanguardia 1969a, 1969b, 1969c). As published in ABC on July 15^th of 1969, one of the Conference’s goals was to reflect on the moral and religious dimension of organ transplantation (ABC 1969b). On the same day, La Vanguardia reproduced the conclusions of the Conference’s Deontology section, comprised by Catholic theologians such as Father Gonzalo Higuera and Father Manuel Cuyás, and theologians from other religions (La Vanguardia 1969a). The main question, again, was the nature of death, left for science to determine.

Coverage of the Conference included a short interview with Father Manuel Cuyás, a Spanish Catholic priest known for his friendly views on organ transplantation (La Vanguardia 1969a). In the interview, he claims that the common good, and not just the donor’s family’s desires, should determine what to do with people’s organs. He even claims that, in some cases, physicians go too far trying to prolong irrecuperable patients’ lives, implying that it is acceptable to stop life support to extract organs for transplantation. Father Cuyás’ statement relies on a medicalized definition of the body that accepts scientific authority and the use of medical technologies as criteria to determine death.

This decisiveness contrasts with the Vatican’s enduring ambivalence. In 1972 -three years after Madrid’s Global Conference- Pope Paul VI’s message to doctors and surgeons was still cautious. In his message, he appeals to “moral sensitivity” and avoids a straightforward answer about brain death, explaining that the Catholic Church “is in no condition to discuss these issues in a specific and scientific manner”, but to “interpret God’s law as it pertains to the defense of all human life since its beginning until its end.” (Efe 1972). Meanwhile, the Spanish Catholic Church had moved away from elucidating the moral character of organ transplantation and had embraced the promotion of organ donation.

Promoting Organ Donation: Generosity, Self-Sacrifice, and Fraternal Love

The altruistic package was present since the beginning of the religious debate around organ procurement, even if it did not become dominant until the 1970s. For example, ABC and La Vanguardia’s praise of Father Gnocchi’s cornea donation draws on this package, and so do later defenses of the morally positive character of organ donation. Additionally, on January 30^th, 1965, ABC published a review of Somatic Law, a book where Father Félix García, a Catholic priest, defends organ donation referring to the Great Commandment and to John 15:13 (ABC 1965). Both biblical sources emphasize fraternal love and self-sacrifice and will become central to the discussion in the following decades.

By the early 1970s, the Spanish Catholic Church had adopted a position favorable to organ procurement, participating in Conferences and events whose goal was, among others, to overcome “unscientific barriers” to transplantation (La Vanguardia 1972). From then on, the debate shifts from negotiating the validity of the sacralized body package to embracing the altruistic package.

When the new democratic government announced a long-awaited Transplantation Law in 1979, the Spanish Catholic Church backed it and started to actively promote organ donation. For example, in January of 1979 several regional dioceses released statements encouraging Catholics to donate organs (Monseñor Ramón Buxarrais 1979; La Vanguardia 1979). In a pastoral letter, bishop of Malaga Monsignor Buxarrais exhorts believers to maintain a “Christian attitude” towards transplantation and invokes the “sad and worrisome” situation of kidney patients awaiting a transplant. He suggests different options for Catholics to help solve this problem, including leaving written testament of one’s willingness to donate organs, and allowing family members to donate their deceased relative’s organs so that “even after death, they can be of service to others”. In another letter, the Diocese of Oviedo’s Health Pastoral describes organ donation as an expression of Christian charity. The letter claims that, given the shortage of transplant organs, “everyone’s effort” is necessary, and so is to “create a conscience of urgency and of duty of charity to offer to our fellow men what we can dispense with without endangering ourselves” (La Vanguardia 1979). While in previous decades religion guided scientific progress and limited potential moral excesses, now science offers new moral possibilities to realize religious altruistic principles.

Following these regional initiatives, reporters questioned president of the Spanish Episcopal Conference Monsignor Vicente Enrique y Tarancón—known for his efforts to establish a positive relationship between the Spanish Catholic Church and Spain’s democratic forces after Franco’s death- about the high proportion of Catholics that refused to donate organs for religious reasons. In his statement to ABC (ABC 1979), he repeats that the Catholic Church does not oppose organ transplantation. On the contrary, he says, the Church had already endorsed it before. Furthermore, Monsignor Tarancón promises that the Episcopal Conference would release an official statement, coinciding with parliamentary discussions about the new Transplantation Law.

The law, which passed in October of 1979, establishes an opt-out procurement system based on presumed consent from the patient (Ley 30/1979). It raised less controversy than one would expect from a society that had just come out of a traditionalist military dictatorship. However, on October 10^th, 1979, ABC and Ya reported on a man who, following the Catholic Eschatological doctrine—particularly the Resurrection dogma—had signed an official document prohibiting medical authorities to extract his organs (Efe 1979; Ya 1979b). In the following years, the Spanish Catholic Church would dedicate considerable efforts to dismiss such claims, championing the altruistic, charitable nature of organ donation.

Once the Law passed, the transplant organs shortage became Spain’s organ procurement system’s main problem. Many patients died waiting to receive an organ. In this context, the Spanish Catholic Church doubled down in its efforts to promote organ donation. For instance, in the Summer of 1980 Archbishop of Valencia Monsignor Roca Cabanellas released a pastoral exhortation explaining believers that “through organ donation we can show our desire to serve Humanity; for Christians, it is a testament to the fraternal love that Jesus Christ demands from us, and for both believers and others with a good will, it manifests their right conscience”. The Law, he adds, is a great opportunity for charity, expressed as the will to offer one’s own body to save or improve someone else’s life (Monseñor Roca Cabanellas 1980). On August 6^th, 1980, Ya echoed this statement, mentioning how Monsignor Roca Cabanellas had specifically dismissed eschatological concerns (Cruz Román 1980).

A few months later, in January of 1981, La Vanguardia reported that Bishop of the Canary Islands Monsignor Ramón Echarren had released a pastoral letter promoting kidney donation (Europa Press 1980). In the letter, he claims that “in the light of the Gospel, in the light of our faith, the great call that we need to feel like a call for love is that many of these patients could heal permanently with a kidney transplant.” He then adds that, when “God calls us to His side, we no longer need them [kidneys]”, and asks, “is there anything more Christian than giving ourselves? Is there any Christian reason that opposes offering our kidneys in the very moment we are giving our life to God?”. Monsignor Echarren bypasses here any possible religious objection to organ donation, framing it exclusively in terms of its altruistic character.

The discovery of cyclosporine -a powerful anti-rejection drug- in the early 80 s stimulated the public conversation around transplantation and organ shortages. For example, on June 6^th, 1984, on the “Religion” section of ABC, Catholic priest and journalist Father José Luis Martín Descalzo shared his experience with kidney disease and how it had made him aware of the dire reality of kidney patients -whom he refers to as “brothers” (Martín Descalzo 1984). Father Martín, addressing those who refused organ donation on religious grounds, explains that Resurrection has nothing to do with preserving one’s organs after death. He adds, paraphrasing John 15:13, that there is no greater charity and proof of fraternity than to give one’s life for a fellow human. He also states that organ donation results directly from a charitable and solidary spirit between fellow Men and insists that the Catholic Church has found no moral obstacles for organ donation, and that refusing donation based on religious motives is not consistent with the “Christian spirit”.

A few weeks later, on July 24^th, 1984, Ya reported in its “Religion” section on a document titled “Solidarity with the sick: Kidney donation”, by a group of Galician Bishops (Ya 1984a). The Bishops argue that religious objections to organ donation are not in line with a Christian spirit and call them “misguided sentimentalisms”. “Christians”, they add, “must convince ourselves that [organ] donation is fully consistent with the line of love and service to fellow Men”. They even deem organ donation “demandable”. Both documents openly dismiss sacralized notions of the body that may hinder organ donation and highlight its altruistic character.

The Spanish Episcopal Conference finally released a long-awaited, official, nation-wide pastoral exhortation, titled “On organ donation and transplantation”, in October of 1984 (Conferencia Episcopal Española 1984). The document defines organ transplantation as a “scientific miracle”, that achieves a “higher form of fraternity”. Transplantation is, then, not only a scientific advancement, but also a moral one, because it allows people to exercise new, previously unthinkable, forms of charity. For the Episcopal Conference, the Catholic Church has the moral obligation to dispel religious objections to organ donation. The Catholic faith, they explain, finds no moral obstacles to organ transplantation. On the contrary, the Church sees it as a precious way to imitate Jesus, who sacrificed his life for others. Through organ donation Men can “come closer to the gratuitous and effective love that God feels for us”. They consider organ donation a “living example of solidarity” and “proof that Mens’ bodies can die, but that the love that sustains them never dies”. This statement appeared on all ABC, La Vanguardia, and Ya in the following weeks (ABC 1984b; La Vanguardia 1984a, 1984b; Ya 1984b) showcasing the official victory of the altruistic package over the sacralized body package.

The organ shortage persisted throughout the 1980s, and the Spanish Catholic Church continued insisting on the Christian and charitable character of organ donation. For example, ABC published an interview with Father Javier Gafo, Jesuit priest and professor of Ethics at Comillas Pontifical University (Spain’s main Catholic University) on October 1^st, 1986 (Fernández Rubio 1986). In the interview, Father Gafo explains that “the [Catholic] Church encourages Christians to support organ donation” from both deceased and living donors. As for religious motives to refuse organ donation—specifically the Resurrection dogma—Father Gafo deems them “fake religious concepts”. He adds that “the best service and the highest respect for a cadaver is that its organs can help other people live” and quotes John 15:13. Sacralized notions of the body that had dominated the religious discussion of organ donation two decades earlier are now downgraded to the category of “fake”.

During this period, members of the Spanish Catholic Church also provided exemplars that consolidated organ donation and transplantation as a reasonable course of action. For example, several bishops signed organ donor cards (Europa Press 1979; La Vanguardia 1981), and some members of the Church disclosed their transplant candidate status (Martín Descalzo 1984).

Mentions of the religious aspect of organ procurement and interventions by Catholic authorities became less frequent after that. While the Spanish Catholic Church continued to publicly support and promote organ donation, by the early 1990s the interpretive dilemma was settled. In the following decade, new bioethical debates displaced organ procurement as objects of controversy.

What Can We Learn from this Case? Discursive Contexts and Facilitating Factors

The case of the Spanish Catholic Church’s support for organ donation and transplantation is not, by far, the only place where a religious group has had to navigate competing theological strands in the public policy arena. Furthermore, even within the discussion of organ transfer, it is possible that the Spanish Catholic Church’s acceptance of this medical practice responds to a global trend—within Christianity or even just within the Catholic Church—towards a greater openness. To elucidate which features make the case at hand particularly illuminating, I examined 24 sources of both primary and secondary literature that explore the relationship between religion and organ transfer in different contexts. While several authors have examined how different religions approach organ transplantation, detailed studies that incorporate historical, cultural, social, and political factors are less common. However, surveying this literature has allowed me to identify what makes the Spanish Catholic Church different from other organized religions in its approach to organ transfer, and a series of facilitating factors that may explain these differences.

The main circumstance that sets the Spanish Catholic Church apart is its early, unequivocal, and continued support for organ transfer which, as shown in the previous section, manifested itself first as an effort to dispel religious objections to organ transplantation and then moved towards an active promotion of organ donation as an expression of Catholic values. Although the II Vatican Council had put some pressure on national Catholic Churches to abandon traditionalist positions and to focus on earthly matters, and although the Vatican has expressed support for organ donation as an act of fraternal love (Abdeldayem et al. 2016; Messina 2015; Oliver et al. 2011)—something that would arguable have created a global incentive for national Catholic Churches to embrace organ transplantation and other scientific innovations—this does not directly translate into immediate and continued support for organ transplantation by individual national Churches and Catholic congregations. For example, as reported in ABC on an article from January 14^th, 1968, Mexican Bishop Monsignor Orozco Lomeli considered that transplants were “immoral” (Efe-Upi 1968). Even in cases where Christian authorities showed initial support for organ transplantation, like was the case of the United States (Efe 1968b), that does not mean that support is unequivocal. In recent years, some American Christian outlets have expressed some concerns about the morality of organ transplantation (Byrne 1999; Kuhn 2008; Meilaender 2007, 2008; Paris 2002; Smith 2013). Not only are there disagreements regarding whether transplants are morally acceptable, but also around what is the most ethically sound way of procuring organs. While the Vatican—and other Christian religious authorities—has repeatedly decried organ sale and organ trafficking as morally reprehensible, some scholars interpret that Thomas Aquinas’ writings on bodily autonomy allow for organ sale (Cherry 2000a, 2000b).

Outside of Christianity, reformist Islamic authorities in Egypt, for example, have also shown early and consistent support for organ transplantation (Hamdy 2012, 2016). However, their approach has revolved mainly around dispelling religious objections to organ donation and transplantation, whereas the Spanish Catholic Church supplemented that strategy over time with a clear and active embrace of organ donation as an expression of Catholic values. In Egypt it would be activists and revolutionaries who, in 2011, would connect cadaveric cornea donation to notions of sacrifice and religious martyrdom in the context of the protests against Hosni Mubarak’s regime (Hamdy 2016).

The Spanish Catholic Church’s level of commitment to support organ transplantation, then, sets it apart from other religious institutions. Comparison with other Catholic and non-Catholic contexts reveals three facilitating factors that enabled and encouraged the Spanish Catholic Church to embrace the controversial medical practice of organ transplantation. First, it is likely that the content of the Catholic doctrine lent itself to the type of reinterpretation that the Spanish Catholic Church performed more than other religious doctrines. Neutralizing the sacredness of the body reinforces a separation between body and soul that was not alien to the Catholic doctrine, and emphasizing altruism and self-sacrifice amplifies a widely known Catholic principle. Besides, the ritual of communion may have acquainted Catholics with the idea of sharing blood and tissues, while the concept of the Holy Trinity may have familiarized them with the notion of an expanded self. Finally, stories like that of St. Cosmas and St. Damian, two Catholic physicians and martyrs who, in the Catholic hagiography, are considered to have performed the first transplant in History, may have helped portray the transplantation of organs and tissues in a positive light.

Comparatively, for Jehovah Witnesses, for example, the notion of organ transplantation may be harder to make culturally acceptable considering their beliefs about blood transfusion. Although technically possible, imagining an organ transplant that does not involve blood transfer is counterintuitive and difficult to convey to believers (Abdeldayem et al. 2016; Messina 2015; Oliver et al. 2011). Similarly, anthropologist Margaret Lock found that popular beliefs about brain death and death informed by Shintoism have historically impeded support for organ transfer in Japan (Lock 2002). In addition to abstract theological principles, it seems like funerary rituals that require a quick burial or that require manipulating the corpse in specific ways are harder to reinterpret. For example, some Muslim traditions mandate that the body should be buried 24 h after the death, which can impede some procurement processes (Abdeldayem et al. 2016; Messina 2015; Oliver et al. 2011).

Some religions, however, may be similarly “friendly” to the idea of organ transplantation. The Hindu mythology, for example, includes several instances of using body parts to help others (Abdeldayem et al. 2016; Messina 2015; Oliver et al. 2011), and some scholars of Buddhism claim that the state of mind in which one dies is more important than the moment of death itself, which would be an argument to support cadaveric donation (Becker 1990). The degree of potential theological compatibility, then, does not suffice to explain why the Spanish Catholic Church embraced organ transfer with such distinctive, early, and persistent enthusiasm.

In that venue, a second factor may have contributed to this outcome. It is worth noting that the Spanish Catholic Church is a unified religious authority that has enjoyed high levels of cultural hegemony throughout Spain’s history. The Spanish Monarchy and the Catholic Church have historically been closely intertwined. Successive Spanish monarchs relied on the Catholic Church to legitimize their power and, in exchange, granted the Spanish Catholic Church a great degree of control over public and private affairs. At the same time, the Spanish Monarchy favored the formation of a national ecclesiastic hierarchy to limit Vatican control. The relationship between the Spanish Catholic Church and the Spanish state was, at least until the late twentieth century, one of mutual dependency.²

The Church’s internal -or at least, apparent- unity, hegemonic position, and relative independence allowed it to make a concentrated effort of interpretation and to avoid the type of intradenominational disputes that have arisen within other religious groups characterized by higher levels of decentralization. For example, the Orthodox Church does not have unified criteria regarding organ donation and transplantation, and it leaves the decision to donate to individuals, who are encouraged to consult with their spiritual advisors. Similarly, and although Protestant denominations tend to support organ donation, most of them consider the decision to donate -and to receive an organ- a strictly individual matter. In the case of Judaism, controversies around brain death have not been resolved, which means that some people of Jewish faith disapprove of organ transfer altogether, while others agree to brain-dead donation, and others indicate that procurement should not begin until their hearts have stopped beating (Abdeldayem et al. 2016; Messina 2015; Oliver et al. 2011). In the United States, for example, positions on organ transfer also vary by denomination, with liberal branches of Judaism expressing more support for organ donation than Orthodox Jews, who are more concerned with the moral validity of brain death (Baeke et al. 2011). Finally, in Islam, the sources of Islamic law do not address organ transplantation nor brain death, scholarly consensus around these issues does not exist, and the existing, non-binding fatwa often contradict each other. In this scenario, families apply independent reasoning, sometimes with help from Ulemas (interpreters of the Islamic law) (Ali and Maravia 2020; Miller 2016; Padela and Basser 2012; Padela and Duivenbode 2018; Padela et al. 2013).

In fact, in context where other religious groups have attempted to lend support to and promote organ transfer, part of their strategy has been to move towards some form of centralization of religious authority, or at least a consensus in bioethical matters. For example, since the nineteenth century, state-aligned reformist Islamic scholars in Egypt have tried to encourage the population to donate their corneas—and later, other organs—after death by dispelling religious concerns around organ transfer and providing them with a unitary set of guidelines (Hamdy 2012, 2013, 2016). Organizations like the Islamic Organization for Medical Sciences (IOMS), the British Islamic Medical Association (BIMA), and the Turkish religious organization Milli Görüs and the Contact Group for the Relations between Muslim Organizations and Government (CMO) in the Netherlands have also tried to reach some degree of consensus to support organ transfer (Ali and Maravia 2020; Ghaly 2012). However, attempts to reinterpret religious texts are often met with resistance by scholars who oppose the idea of manipulating religious doctrine in order to provide support for organ transfer (Rady and Verheijde 2014).

Finally, the sociopolitical context of Spain during the 1960s, 70 s, and 80 s (when most of the theological debate around organ transfer took place) provided a conducive background for the Spanish Catholic Church to both embrace organ transplantation and to actively promote it. On one hand, organ transfer enjoys a peculiar cultural salience in Spain, and has done so since its early days (Herrero Sáenz 2022). The Francoist regime made a considerable effort to publicize Spanish surgeons’ achievements in transplantation, with the intention of counteracting negative perceptions of Spain and signaling development to both domestic publics and the international community (Danet 2013; Danet and Medina-Doménech 2014, 2015; Herrero Sáenz 2020). Later, successive democratic governments have made a substantial investment in building an effective organ procurement system and in encouraging the population to donate their organs (or, more often, their relatives’). Resulting from these efforts, organ donation rates have increased dramatically in Spain in the last 30 years, and the country currently occupies an undisputed leading position in the global organ donation rankings. Internationally recognized actors such as the World Health Organization (WHO), the Council of Europe, and the leading scientific journal American Journal of Transplantation consider the “Spanish Model” (Matesanz 2008) the gold standard of global procurement (Matesanz et al. 2009; Sharif 2017). This amount of recognition and praise has resulted in an outstanding social acceptance of organ transplantation (Centro de Investigaciones Sociológicas 2001, 2004, 2012).

On the other hand, during the second half of the twentieth century, the social influence of Catholicism in Spain declined. First, Church and State grew apart, especially after dictator Francisco Franco’s death in 1975, when Spain’s democratic transition reduced the Catholic Church’s privileges. During the Civil War and the first stages of the Francoist dictatorship, the Catholic Church had supported the regime, participating in the post-war repression and becoming an integral part of the Francoist establishment (Astor et al. 2017). “National Catholicism” was a central component of Franco’s official State ideology and identity. After the Second Vatican Council (1962–1965), which encouraged national churches to move away from transcendental positions and embrace their role in solving earthly social problems, the Spanish Catholic Church moved towards more open positions (Montero García 2009). After Franco’s death in 1975, the Church -led by Cardinal Monsignor Vicente Enrique y Tarancón, president of the Spanish Episcopal Conference- supported Spain’s democratic transition, even if that meant giving up some of the prerogatives that the Spanish Catholic Church had acquired during the dictatorship and softening some of its more traditionalist stances. In exchange, the Spanish Catholic Church maintained a privileged political and social position.

Second, a rapid process of secularization started in the 1960s and grew during the 1970s and 1980s. Religious practice declined, and so did religion’s importance in people’s lives and decisions. On one hand, by participating in the Francoist regime the Spanish Catholic Church alienated a good portion of the population, who saw Spain’s democratization as an opportunity to move away from religion in general and Catholicism in particular. On the other hand, younger generations were losing interest in religion and religious practice (Pérez-Agote 2012).

In that sense, the Spanish Catholic Church attempted to make Catholic beliefs more compatible with the current social, cultural, and historical milieu (Swart 1995). The link between sociopolitical contexts and religious interpretations of medical innovations, and specifically of organ transfer, has not been studied in detail. However, authors like Margaret Lock and Sherine Hamdy have found that in Japan and Egypt, respectively, religious opposition to organ transfer has to do with wider crises of authority and trust in institutions (Hamdy 2012, 2013, 2016; Lock 2002), which in the case of Egypt changed with the 2011 uprising and the symbolic connection between mass eye trauma, cornea donation, and religious martyrdom (Hamdy 2016). In his study “Islam and organ donation in the Netherlands”, Mohammed Ghaly found that it is not possible to understand Muslim organization’s interest in supporting organ donation without considering ongoing accusations against the Muslim population of not donating enough organs and taking advantage of the Dutch organ procurement system and, more widely, without considering the rise of islamophobia in the region (Ghaly 2012). In these examples, the social, cultural, and political milieu is, in itself, a condition of possibility for institutional religious support for organ transfer.

In sum, the first experiments in organ transplantation put the Spanish Catholic Church in a delicate predicament. As one of Spain’s highest moral authorities, it was expected to provide non-specialists with a coherent moral framework to evaluate this new medical practice (Ecklund et al. 2017, 294), which meant working through the contradictions between the altruistic and the transcendental elements of its doctrine. In this scenario, the Spanish Catholic Church had at least four potential courses of discursive action (see Table 3) based on whether it would emphasize or neutralize each of its doctrinal interpretive packages:

Table 3 The Spanish Catholic Church’s potential courses of discursive action in relation to organ donation and transplantation

The Spanish Catholic Church could have (A) distanced itself from the debate and left moral decisions about organ donation and transplantation in the hands of individuals. Other religious institutions and leaders have taken that path (Ali and Maravia 2020; Baeke et al. 2011; Miller 2016; Padela and Basser 2012; Padela and Duivenbode 2018; Padela et al. 2013). However, this would have weakened the Spanish Catholic Church’s position as a moral arbiter and would have been a missed opportunity to maintain its cultural relevance. It could have (B) opposed organ transfer, highlighting Catholic beliefs about the sacredness of the human body, but that would have put it at odds with Spain’s political elites. People’s increasing disinterest in religion was also a factor in pushing the Spanish Catholic Church towards a more open position regarding certain forms of scientific and medical progress, especially as controversial questions like divorce and abortion became a point of friction between the Church and Spain’s progressive forces. Alternatively, the Spanish Catholic Church could have (D) tried to hold on to and reinforce both its beliefs about generosity and charity and its beliefs about the sacredness of the body, but that would not have solved the contradiction and could have sparked some degree of backlash. Aligning Catholic beliefs with discourses around organ transfer by suppressing sacralized notions of the body and emphasizing values of charity, altruism, and generosity (C) avoided the potential pitfalls implied in all the other options, and therefore was the best course of discursive action for the Spanish Catholic Church.

Discussion

Organ transplantation confronted the Catholic Church with a contradiction between its altruistic principles and its ideas about the sacred character of the human life and body. My findings show that, faced with this interpretive dilemma, the Spanish Catholic Church did extensive interpretive work to align organ donation and transplantation with Catholic beliefs, but did so within the limits established by the internal logics of preexisting meaning structures that made organ donation and transplantation both potentially acceptable—as a form of altruistic behavior—and unacceptable—as a practice that contradicts sacralized meanings of the body—for Catholicism.

The cultural dynamics I described above, however, do not completely determine institutional agency. The interests of the Spanish Catholic Church, and the sociohistorical factors that surrounded it during the time organ transplantation emerged as a therapeutic option, shaped its institutional discursive strategies. In this case, the relationship between the Catholic Church and organ procurement in Spain is one of reciprocal legitimation. On one hand, aligning organ procurement with Catholic beliefs contributed to legitimize and normalize it. On the other hand, publicizing its support for organ donation gave the Spanish Catholic Church the chance to recast itself as a modern social and political actor, at a time where it was facing a legitimacy crisis.

Comparing the Spanish case with other instances of religious interpretation of organ donation and transplantation reveals three facilitating factors that enabled and encouraged the Spanish Catholic Church to embrace organ donation and transplantation. The degree of potential theological compatibility between a religious doctrine and the practices and discourse of organ transfer, the degree of consensus and unity within institutionalized religions, and the larger social, political, and cultural climate both encourage and constrain religious institutions’ support for organ transfer. While none of these factors are a sufficient condition for religious institutions to take a particular stance about a new medical practice, they provide background conditions that facilitate religious agreement with scientific innovations.

My findings, and their theoretical implications, can be fruitful for various scholarly fields. For sociologists of culture, they build on an interpretive approach to the relationship between beliefs and practices that respects the relative independence of cultural dynamics operating at the level of meaning, while also accounting for institutional discursive agency and situating it in a concrete sociohistorical context (Alexander and Smith 2006; Kane 1991). For medical sociologists, my findings add to the well-established literature on the cultural legitimation of medical practices (Blume 2013; Joyce 2005), in this case focusing on how religious arguments can contribute to normalize an initially shocking medical procedure. Finally, public health scholars can benefit from my findings to understand the challenges that institutionalized religions face when confronted with controversial medical practices that raise conflicts within their own doctrines. This, in turn, can foster a better understanding and smoother avenues for collaboration between medical institutions—such as organ procurement organizations—and religious authorities (Randhawa and Neuberger 2016). Given that, for many, organ donation—of their organs or their relatives’—elicits religious dilemmas, understanding these more profoundly is crucial to explain and mitigate the perennial transplant organ shortage.

Besides interpreting discursive processes, my findings raise questions of causal efficacy: Did the support of the Spanish Catholic Church contribute to increase the social acceptance of organ transplantation in Spain? My study does not directly address how the Church’s messages affected people’s subjective experience, but it is possible. Making the altruistic package more readily available for people to employ as a resource for their moral evaluation of organ transplantation (Ecklund et al. 2017) may have stirred Catholics towards supporting organ procurement by providing them with “religiously-based rationales for social action” (Edgell 2012, 251). Furthermore, media made this cultural repertoire publicly available to Catholics and non-Catholics, amplifying its reach beyond religious individuals (Lichterman 2012). In a context like Spain where the Catholic Church had enjoyed centuries of hegemony, it wouldn’t be surprising for these moral evaluations, initially of religious origin, to become “culturalized” (Astor and Mayrl 2020), and relevant for non-believers.

It is also possible that the Church’s campaign had little impact on people’s actions. Although the Spanish Catholic Church’s leadership supported organ transplantation unequivocally, the institution is not ideologically homogeneous (Pérez-Agote 2012), and believers were probably exposed to competing claims about both the moral character of organ donation and to different interpretations of what it means to be Catholic (Baggett 2006). The messages that priests across the country were circulating among their parishioners might have differed from what the Episcopal Conference was preaching. Although previous scholarship has addressed the ideological heterogeneity within the Spanish Catholic Church (Montero García, 2009), to the best of my knowledge its impact on the debate on organ procurement remains underexplored.

Besides, although we can presuppose that the Church’s messages had a certain influence on the public, my findings do not speak to how people engaged with these messages and whether they shaped their attitudes and actions. People engage actively with cultural meanings, including religious messages (Fisher 2012), and actors can draw on different interpretations of the Catholic doctrine and mobilize them towards opposed goals. Furthermore, Catholics may also employ secular principles of evaluation to assess the moral character of organ transplantation (Edgell and Hull 2017).

Despite its limitations, an approach focused on contextually situated meaning-making processes is also applicable to other cases of religious interpretations of medical innovations and public health issues. While religious controversies about abortion, euthanasia, or stem cell research immediately come to mind, other medical and public health issues with less obvious religious ramifications are worth exploring. For example, authors have found that religious ideas are shaping people’s likelihood to get vaccinated against COVID-19 (Corcoran et al. 2021; Garcia and Yap 2021; Milligan et al. 2021) and against other diseases. To understand the linkage between religion and vaccine hesitancy it is crucial to examine how certain religious groups and organizations interpret these medical innovations and the public health rationales for vaccination, and in what sociopolitical context they produce these interpretations.

In sum, controversial medical innovations and public health issues sometimes reveal moral contradictions that face religious organizations with interpretive challenges. In such moments, religious institutions generate context-specific creeds and moral guidelines, but they do so while navigating doctrinal, institutional, and sociopolitical conditions that enable, constrain, and shape the reinterpretation of religious texts.

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