Organ Donation in Israel—Achievements and Challenges

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Israel's organ transplantation history dates back to 1964 when the first kidney transplantation from a living related donor was performed; the first kidney transplantation from a deceased donor followed in 1965. Currently, organ transplantations are performed in 6 Israeli medical centers with 6 kidney, 3 liver, 3 hearts, and 2 lung transplantation programs. All donor management and organ allocation are centrally coordinatedbytheIsraelNationalTransplantCenter(INTC) which was established in 1994 as a department within the Ministry of Health and functions through the work of nurse donor coordinators in each of the 16 large hospitals in Israel. An additional intensive care unit physician has been assigned in each of these 16 hospitals with responsibilities in supporting coordinators with donor management, appealing, and consenting for organ donation and the donation process. 1 TheINTC's responsibilities include maintainingupdated lists of transplant candidates and the coordination of procurements and organ allocation to all transplant programs. External auditors review all medical records of fatalities with the diagnosis of brain pathologies at regular intervals to assure identification of brain death and quality of donor management. A recent report documented that 98% potential brain-dead donors have been identified. Brain Death Determination and Deceased Donation Israel is a multicultural society with different religions— Jews, Muslims,Christians, and Druzes—and multiple ethnicities. Despite of Israel's economic strength and well-organized health care, deceased organ donation rates have consistently been low compared to most other Western countries. The most common reason for refusal to donate had traditionally been based on religious objections. 2 Many Jewish rabbinical leaders support the concept of brain death and consider organ donation as a noble decree. At the same time, a minority of only 8% of the population are ultraorthodox Jews who follow a strict interpretation of Halacha laws that define the time of death as the moment of cessation of cardiac and respiratory function, and therefore do not accept brain death. Yet, at times of despair, many of the additional 12% of the Jewish population who define themselves as “religious” and 13% who are “religious-traditionalists” tend to favor the stringent ultraorthodox interpretation of death criteria and therefore reject organ donation after brain death. 2 Moreover, 1.7 of 8.2 million Israelis are Arabs, mostly Muslims (83%), with additional cultural and religious barriers to organ donation. In 2008, the Israeli Parliament has adopted the BrainRespiratory Death law representing a consensus between medical community and religious authorities that define the criteria and diagnosis of brain death. 3 Brain death is documented by mandatory performances of an apnea test and an ancillary imaging test demonstrating the absence of blood circulation within the brain. Despite its strict implementation, the law has not yet received the anticipated response among rabbinical leaders, who still shy away from advocating organ donation. An additional cause of low donation rates is the so-called free-riding behavior of those who reject brain death and thus organ donation, yet do not abstain from being active candidates for organ transplantation themselves. This phenomenon causes significant antagonism toward organ donation in many circles and has been repeatedly cited in public opinion surveys in Israel as one of the major reasons for the low consent rate for organ donation. 2 To overcome this behavior and to incentivize deceased organ donation, the new Organ Transplant law includes a unique clause which grants prioritization to candidates who have either been registered as organ donors for at least 3 years before being listed, or have a first degree relative who has been a deceased organ donor, or have previously donated a kidney or a liver-lobe 2 Al ower priority is granted also to candidates whose first degree relative has been a registered donor for at least 3 years; however, this category of prioritization will soon be eliminated. 4 The preliminary results after implementation of this new policy show a significant rise in the number of new registered donors per month, and, most importantly, a significant increase in the actual consent rate for deceased organ donation from