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Israel finds a Formula for Increasing Domestic Donations

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 Itongadol.- Faced with rabbinic resistance and social ambivalence, the government has pioneered a program that rewards a willingness to donate

A decade ago, Israelis were among the world’s leading “transplant tourists”—a phenomenon driven in large part by Israeli insurers’ willingness to reimburse the costs of transplant operations abroad, which gave Israelis of all means access to the international organ trade. The laissez-faire stance of the Israeli government was in large part due to persistent shortages of domestic organ donors.

Yet, as horror stories about overseas organ transactions seeped into public awareness, doctors—including Jacob Lavee, director of the heart transplant unit at Sheba Medical Center in Tel Hashomer—and others began lobbying for changes to Israel’s laws governing transplants. In 2008, the Knesset ratified the Organ Transplant Act, which outlawed giving and receiving compensation for donations—both inside and outside Israel. Abolishing a commercial source of organs necessitated that Israel find a way to induce a dramatic increase in its number of donors to counterbalance the loss—immediately. Failure meant many of those waiting for transplants would die.

Increasing domestic donations is a special challenge in Israel, where religious factors have historically constrained the organ supply. Despite a 300-year-old rabbinical ruling that an autopsy—and by extension, any post-mortem surgery—can be performed to save a life, many observant Jews consider the body inviolate in death. Taboos against mutilation are less of an issue in other Western countries, where consent rates—the percentage of brain deaths that result in donation—frequently exceed 70 percent. For most of the 2000s, Israel’s hovered around 45 percent—among the lowest in the developed world.

Today, however, Israel’s consent rates have jumped, to 56 percent in 2013—still low, but a shift that demonstrates a real turnaround in public opinion surrounding organ donation. The change is largely due to the public debate surrounding brain death that followed the highly publicized decision by the family of the Israeli soccer star Avi Cohen to disregard his wishes to donate his organs after a 2010 motorcycle accident left him brain dead—and to Israel’s adoption of a unique allocation system for organs that rewards those willing to donate. At a time when waiting lists are growing everywhere, including in the United States, Israel’s success has implications for a global transplant landscape that is in dire need of innovation.

But it took another two years before Israel instituted its second, and perhaps more crucial, policy response to the organ shortage—a pioneering approach that gives transplant priority to those willing to contribute to the organ pool. Launched in April 2012, the new Israeli system grants first priority for transplants to living donors and the family members of donors—who, in the event of brain death, make the ultimate decision whether to donate their kin’s organs. Registered donors of three years or more receive second priority; family members of registered donors receive a third tier of priority.

The system confers an advantage to candidates in the same tier of need; it never enables transplant candidates to supersede needier counterparts. Priority can’t catapult Status 2 recipients into the heart-transplant Status 1 list, but it can take them to the top of Status 2. With other organs, like kidneys, where a point system assigns values weighing age, waiting time, and compatibility create a 0 to 18 score, signing up as a donor can add a 1- to 5-point boost.

Priority allocation rewards a willingness to donate and penalizes free-riding behavior that in the past afforded Israelis with no intention to donate equal access to organs. This is a major departure from the status quo – Israel is the first nation to incorporate non-medical factors into organ allocation on a national scale. (It has precedents in Singapore, where opting-out of implied donor consent pushes transplant candidates down the waiting list should they need an organ, and the United States, where living kidney donors have transplant priority status should they likewise need it.)

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