Academic journal article Law and Contemporary Problems

Reciprocal Altruism - the Impact of Resurrecting an Old Moral Imperative on the National Organ Donation Rate in Israel

Academic journal article Law and Contemporary Problems

Reciprocal Altruism - the Impact of Resurrecting an Old Moral Imperative on the National Organ Donation Rate in Israel

Article excerpt



Israel's organ-transplantation history dates back to 1964, when the first kidney transplantation from a living related donor was performed. (1) In 1965, the first kidney transplantation from a deceased donor was successfully accomplished. (2) Currently six Israeli medical centers perform kidney, heart, lung, and liver transplantations. (3) The Israel National Transplant Center (INTC) coordinates all donors and transplantations. (4) INTC coordinators are in every medical center in the country. (5) Despite this, the deceased-organ-donation rate in Israel has traditionally been among the lowest in Western countries, ranging between seven and eight deceased donors per million population. (6)

There are numerous past and present causes of the low donation rate. One major cause is the refusal of some ultraorthodox religious groups to recognize brain death as a valid determination of death. (7) These groups may refuse organ donation from individuals who are brain dead but do not meet other criteria. (8) Many mainstream rabbis accept brain death as a valid determination of death and consider organ donation one of the highly noble deeds in Judaism. (9) However, the vocal objection from ultraorthodox rabbis has widespread consequences since, during critical moments of life, many Israelis, mainly religious but also secular, seek comfort and advice from various religious leaders and tend to accept their judgment. (10)

An additional cause of the low donation rate is the so-called "free-riding" behavior of those who reject brain death as a valid determination of death yet are prepared to be organ recipients from brain-dead donors. (11) This phenomenon spurs resentment to organ donation and is cited in Israeli public-opinion surveys as a major reason for the low consent rate. (12)

Another important cause was, until recently, the relatively inexpensive availability of transplant tourism for Israeli patients. The Ministry of Health allows Israeli hospitals to perform kidney transplants only from either living related or purely altruistic non-designated donors, following approval by special national transplant ethics committees. (13) Candidates for kidney transplantation who identify fellow Israelis who are willing to sell one of their kidneys are prohibited from undergoing surgery in Israel. (14) Accordingly, instead, many of them used to travel with their donors to countries such as Turkey, South Africa, Bulgaria, Azerbaijan, or Sri Lanka for the surgery. (15) In the majority of cases, Israeli transplant tourists received kidneys from foreign paid donors in the donors' home countries--mainly the Philippines, but also China and Colombia. (16) Due to a lack of meaningful legal obstacles up to the year 2008, Israeli insurance companies and sick funds used to incentivize this transplant tourism by fully reimbursing transplant operations performed abroad regardless of the legality of the operations under local law. (17) These reimbursements were motivated by both the desire to help desperate patients overcome the local organ shortage and considerations of economic efficiency as these patients were taken off the costly dialysis list. (18) Moreover, middlemen, who were motivated to expand the transplant tourism market, have emerged between the donors and the insurance companies or sick funds, thereby exacerbating the problem. (19)

Finally, altruistic organ donation was also traditionally underutilized due to a variety of disincentives, mainly involving lack of any reimbursement to live donors for their incurred expenses and loss of income

In response to all of these obstacles to organ transplantation, on March 31, 2008 the Israeli Parliament passed into legislation two laws relevant to organ transplantation. (20) The laws aim to halt illegal transplant tourism while increasing local organ donation from both deceased and living donors. They are designed to increase consent rates for both deceased and live donation by cutting off transplant tourism, incentivizing registration for deceased donation, and removing disincentives for live donation. …

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