Who Deserves a Heart Transplant?

In Israel, a New Approach to Organ Donation

by Danielle Ofri
New York Times

One of the most agonizing spots in medicine is the “transplant list.” When I’ve referred patients for organ transplant—heart, liver, kidney—it is the start of an anguished wait. The clock ticks for my patient as we watch her clinical status decline, all the while harboring that excruciating hope that someone will die soon enough to make an organ available. In the case of kidney donation, which can come from a live donor, it is the desperate hope that someone will decide to make this enormous personal sacrifice. Some of my patients have died waiting, which is, sadly, not an unusual outcome. It is estimated that 18 patients on the waiting list in America die every day. In the United States, as in many countries, we rely on a simple system of altruism, or what might be called the opt-in approach. We hope that people will sign organ donor cards because they think it is the right thing to do, or that families will consent to donation after a loved one has suffered brain death because it will help someone else. But these mechanisms do not result in nearly enough organs for all the patients who need them.

Other countries, like Spain and Austria, have tried an opt-out approach, called presumed consent. Every patient who dies is assumed to have consented to organ donation, unless they have specifically declined. However, this hasn’t necessarily increased the number of organ donations, in part because doctors find it extremely difficult to go against family wishes if surviving family members are strongly opposed to donation.

I recently learned of a third way to increase donations, being pioneered in Israel. Up until now, Israel ranked at the very bottom of Western countries on organ donation. Jewish law proscribes desecration of the dead, which has been interpreted by many to mean that Judaism prohibits organ donation. Additionally there were rabbinic issues surrounding the concept of brain death, the state in which organs are typically harvested. As a result, many patients died waiting for organs.

So Israel has decided to try a new system that would give transplant priority to patients who have agreed to donate their own organs. In doing so, it has become the first country in the world to incorporate “nonmedical” criteria into the priority system, though medical necessity would still be the first priority.

The Israeli program was initiated by Dr. Jacob Lavee, a cardiothoracic surgeon who heads the heart transplant program of Sheba Medical Center in Tel Hashomer. In 2005 he had two ultra-orthodox, Haredi Jewish patients on his ward who were awaiting heart transplants. The patients confided in him that they would never consider donating organs, in accordance with Haredi Jewish beliefs, but that they had absolutely no qualms about accepting organs from others.

That Haredi Jews would not donate organs was a well-known fact in Israel But this was the first time anyone had openly admitted the paradox to Lavee.

The unfairness of a segment of society unwilling to donate organs, but happy to accept them, nagged at Dr. Lavee. After he operated on both patients, giving each a new lease on life, he put together a proposal that would give priority to those patients willing to donate their own organs.

Working with rabbis, ethicists, lawyers, academics and members of the public, he and other medical experts worked to create a new law in 2010, which will take full effect later this year: if two patients have identical medical needs for an organ transplant, priority will be given to the patient who has signed a donor card, or whose family member has donated an organ in the past.

A critical component of the law’s success was engaging the country’s highly influential religious leadership, which had long been resistant to organ donation. Even among the half of the country that is devoutly secular, when faced with death and whether to donate organs, “Suddenly the families become very religious. Suddenly they ask the rabbis,” said Dr. Yael Haviv, the medical director of the organ donation program at Sheba.

But in the Talmud, saving a life supersedes most everything, and many commandments may be transgressed if the goal is to save a life. Based on this, the argument could be made that organ donation fulfills one of the highest religious virtues. The lawmakers also agreed on a definition of brain-death that was acceptable to the vast majority of rabbis (though not the ultra-orthodox Haredi), as well as local imams, making organ donation kosher to a large segment of the population.

This was accompanied by a massive public awareness campaign about organ donation, with radio, TV, billboard and newspaper ads promoting the new priority system and countering the perception that Jewish law forbids donation. Shopping centers and coffee houses were blanketed with organ donation information. The response was overwhelming, as people registered in droves as potential donors.

“We were swamped,” says Tamar Ashkenazi, the direction of the National Transplant Center of Israel. The machine that actually prints the organ donation cards usually handles 3000 per month—5000 if two workers are dedicated full-time to operating it. During the ten weeks of the publicity campaign, 70,000 Israelis registered for organ donation cards.

The consent rate from families has already increased, and the number of organs available for patients has increased in parallel. Transplants have so far increased by more than 60 percent over all this year.

Other aspects of the new law provide “fair compensation” for living donors that covers 40 days of lost wages, plus expenses related to the donation. “This serves to remove the disincentives to donation,” Dr. Lavee says. Kidney transplants from live donors — nearly always from family members of patients—have increased dramatically.

The new system, though, is not without its critics. Many say that any “nonmedical” factors in organ allocation are inherently unethical. Some say that the law enshrines religious discrimination, since Haredi patients decline to donate based on their religious beliefs.

But many feel that the new law adds a measure of fairness to the process., and now there are more organs available for everyone. It will be interesting to see how things play out when the priority system actually goes into effect on April the 1st.