Medical Examiner: Kidney Mitzvah
Kidney Mitzvah
Israel's remarkable new steps to solve its organ shortage.
By Sally Satel • Slate
This month, Israel launched a new policy to encourage organ donation: Anyone who registers to allow his organs to be taken posthumously gets slight priority if he needs one in the future. When two comparably ill patients are in need, the tie will go to the organ-donation cardholder. The new policy garnered publicity in the Australian, Canadian, South African, and British press.
Meanwhile, under the radar, another, more dramatic Israeli initiative took place: giving compensation to families of deceased organ donors.
On Jan. 20, the relatives of a 51-year-old deceased man named Nachis Yafim gathered to accept a check for 10,000 Israeli shekel (roughly $2,700) in recognition of his wife Clara's decision to allow his liver, kidneys, and lungs to be taken for transplantation. The funds will be used by Clara and their 10-year-old son to memorialize Nachis—by paying for his headstone, for example.
In legalizing such a "memorial," Israel thus becomes the first country in the world to reward deceased organ donors. The Organ Donation Law, passed by the Knesset in 2008, says that families who agree to donate the organs of deceased loved ones may accept money to "memorialize" the deceased. Currently, the Israeli Ministry of Health has allowed up to 50,000 shekel, or $13,400, to do so. The money—given by nonprofit groups and taken out of their own pool of charitable contributions—may be used in any way the families see fit to memorialize the deceased.
According to the law, the donor, while alive, must not have refused to become a posthumous donor. This quells anxiety about a family benefiting over the objections of the donor himself.
The money for Nachis Yafim's family was given by ADI, a nonprofit organization outside of Tel Aviv that was established to encourage organ donation. It is named for Adi Ben Dror, who died of complications of kidney disease.
In the ceremony held in honor of Yafim, who emigrated from Russia and worked as a security guard in Be'er Sheva, Gadi Ben Dror, the director of ADI, said, in handing the check to Clara, "In this country we always talk about military heroism. ... [T]his is clearly a case of civilian heroism. [His organs] saved four lives. ... [T]he family should be blessed."
Donation at death is a big deal in Israel because of its infrequency. The country is lodged far down on the list of developed countries regarding the availability of deceased organs for transplantation: Nine donors per 1 million people. In comparison, that number is 35 in Spain and 25 in the United States. As of last year, only 8 percent of adult Israelis held organ-donor cards. In Europe, the rates are between 30 percent and 40 percent. In the United States, about 38 percent of adults with a driver's license were registered organ donors in 2009. In addition, the "conversion rate"—that is, the percentage of times a death meeting eligible criteria for donation becomes an actual donor—is 60 percent to 70 percent in the United States. (The rate depends, in large part, on whether families of deceased people agree when asked to give permission to retrieve the organs of loved ones—yes, even if one signs a card, hospitals will allow families to override the deceased donor's indicated preference.) In Spain, the conversion rate is around 80 percent. Israel's conversion rate is 45 percent.
Why such low rates? "Most Jews are under the mistaken impression that traditional Jewish law requires a body be buried whole at all costs," according to Robby Berman, director of the Halachic Organ Donor Society, an organization that encourages Jews all over the world to donate organs to the general population.
Another barrier to deceased donation has been the definition of death. Some ultra-Orthodox rabbis reject brain death as the definition of death because the ventilator is providing oxygen that allows the heart to beat for a few more days after brain death. They insist that the heart must cease to beat before a person can be pronounced dead—a condition making it difficult to obtain suitable organs in a timely manner. To facilitate donation, Israel passed a law in 2008 establishing "brain death" as the definition of death relevant for all legal purposes, including organ donation.
Why is Israel working so hard to increase donation now? Because Israelis can no longer participate in transplant tourism—that is, go abroad to obtain organs.
In 2008, a new law mandated that the Israeli Ministry of Health stop paying for transplants that were obtained in countries that themselves outlaw organ sales. This brought a stop to a policy that was in effect since 1998, when the ministry began covering the cost of transplants obtained from foreign donors. Israelis seeking organs had traveled to places such as Turkey, China, Eastern Europe, and the Philippines, though the exact number of transplant "tourists" is not known. As more Israelis received transplants this way, rates of donation by living relatives went down, according to the Ministry of Health.
Israel should be commended for moving to solve its organ problem, and save lives, by making two moral choices: first, to reduce transplant tourism; second, to provide compensation for deceased donation and priority ranking to encourage donations. This symmetry is critical to reducing the organ shortage in Israel and all over the world. Incentives must be paired with efforts to combat trafficking.
Alas, the World Health Organization, the Council of Europe, the United Nations, and the International Transplantation Society fail to grasp the need for such a two-pronged strategy. Instead, these groups endorse a strictly unilateral policy that bans organ trafficking. At first blush, yes, this seems reasonable. After all, corrupt brokers deceive indigent donors about the nature of surgery, cheat them out of payment, and ignore their post-surgical needs.
But clamping down on unlawful organ sales without first expanding the organ pool means more patient deaths, not less criminal activity. It drives corruption rings further underground or causes markets to blossom elsewhere around the globe. This is happening now. As China, Pakistan, and the Philippines have begun to curb illicit organ sales, places like Egypt, Eastern Europe, and South and Central America are becoming popular "tourist" sites.
Indeed, the global transplant establishment is so leery of benefiting donors or families directly—as in, for example, allowing Clara to use the 10,000 shekel to pay bills now that her husband is gone—that Israel had to put limits on how the cash was spent. I think this is too bad. Yafim would surely want his family to have some short-term financial cushion. Moreover, freedom to use the benefit as the family decides might be an even better incentive to donate.
Nonetheless, the compensation-for-memorialization is an important development that more countries should adopt.
When Gadi Ben Dror presented the check to Yafim's family, he said, "[We] owe the family our appreciation [which] we express with a gift. It's important to publicize their courage to donate organs in order to encourage others to donate as well." Within those sentiments lies the solution to the organ shortage: expressions of gratitude for a life-saving act intended to encourage others to do the same.
Sally Satel, M.D., a resident scholar at the American Enterprise Institute, is editor of When Altruism Isn't Enough: The Case for Compensating Kidney Donors.
What's Really Behind Israel's New Organ Donation Policy.
[Hat Tip: Joel Katz.]
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