Ethical Issues in Organ Transplantation in Israel

- Gershon B. Grunfeld, Ph.D.,
Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, P.O.B. 9649, 31096 Haifa, ISRAEL

Eubios Journal of Asian and International Bioethics 6 (1996), 169.
Organ transplantation was one of the major turning points in the development of biomedical ethics. It started with the first successful kidney transplantation, performed by Drs. Hufnagel, Landsteiner and Hume in Boston in 1947. But only after another ten years, when a way was found to overcome the body's immunological rejection, was the road open to large-scale organ transplantations and not limited to the few who were fortunate enough to have an identical twin. In the mid-1970s a new drug, cyclosporine, offered promise for a much wider and more successful application of transplantation techniques. Combined with a marked improvement in the technical abilities of medicine, life-sustaining machinery, accurate tissue typing, and more, the science of transplantation experienced a renaissance limited only by the scarcity of donated organs. Organ transplantation raised many difficult ethical dilemmas, some discussed by Dr Tharien in an Indian context. The most prominent of which was the allocation of scarce resources. This question was first raised following a medical development in the case of the kidney-dialysis machine. In that instance, the story of the Swedish Hospital in Seattle, Washington, where a citizens' committee determined access to dialysis, thereby deciding who would live and who would die, was brought to public attention (1). The solution to that dilemma was quite unusual and, to my knowledge, was never repeated anywhere. The American Congress decided to fund such technology for all who needed it. The Congress did not take similar action after the artificial heart was developed. In any case, it is clear that a financial allocation alone will not solve the problem of organ transplantation. Organ transplantation has also challenged the ancient principle of primum non nocere. In the case of living donors, a healthy bystander might be harmed in order to benefit the patient. The traditional "First, do no harm" was replaced by a question of probabilities: "What is the likelihood of harm being done, as opposed to the likelihood of good accruing to the patient?"(2). Progress in the field of transplantation also enhanced other philosophical discussions about the definition of death. A revision in the definition of death was discussed and suggested in 1968 by a committee at Harvard Medical School (3).

Israel suffers from a chronic, continually increasing shortage in organs for transplantation, while the willingness of the public to donate organs dropped 25% last year. Unlike some countries in Europe, Israel has not adopted (and probably will not adopt) a system of presumed consent for cadaveric organ donations. The current system in Israel requires permission to be granted by the family of the patient before an organ can be used. While there is a central registry (managed by the Ministry of Health) of people carrying donor cards to be used in the event of death, the number of those carrying the card is approximately 79,000 (4) out of a general population of over 5 million people. Although the central registry has been active for many years, all attempts to increase the number of registrants have failed. Currently, in the event of death, family members usually get veto power over the choice of their loved one. On the other hand, until recently, relatively little was done to train teams for approaching families and asking for organ donation in the event of brain death. Interestingly, the Israeli Anatomy and Pathology Law (1953) allows for "using part of a corpse when it is needed to save the life of a person" without any consent. This law has very rarely been used and on one celebrated occasion may have brought more damage than benefit. On June 19, 1993, a heart, liver, lungs, and kidneys were harvested from an anonymous traffic accident victim in Beersheba and transplanted in five patients in Israel. After all attempts to identify the family failed, the hospital staff harvested the organs without consent. This person was not carrying a donor card. The story was described on the front pages of the daily newspapers as a case of "organ robbery," and public response was so unfavorable that no similar attempts have been made since. Until very recently, the six large transplantation centers in Israel did not share information, kept separate waiting lists, and cooperated only on an ad hoc basis. That changed with the establishment of the Israeli Center for Transplantation, which will also coordinate educational efforts to increase the willingness of the public to donate.

The shortage of organs for transplantation in Israel has also created practices that are far from ethical. In recent years reports have been published in Israel about Israelis who travel to neighboring countries (especially Egypt) and buy a kidney for transplantation from poor immigrant workers. Some papers have even reported the existence of such practices in Israel, which are currently being investigated by a governmental commission. Interestingly, the Jewish Halacha does not forbid selling or buying organs from the living, even if the seller is poor or in debt (5). With more than 2,000 Israeli patients currently dependent on dialysis, more than 700 patients waiting for transplantation, only about 100 kidney transplants a year, and no prospects in the current system of solving the shortage in kidneys for transplantation, Israel will have to face the challenge of developing a regulated system for living-donor organ donations. This will still leave the problem of shortages in other organs unresolved.


1. Alexander S, They decide who lives, who dies. Life, 9/11/1962, pp.102-25.
2. Moore FD, Three ethical revolutions: Ancient assumptions remodeled under pressure of transplantation. Transplantation Proceedings, 1988;20:1061-67.
3. Ad Hoc Committee of Harvard Medical School, A definition of irreversible come: Report of the ad hoc committee of Harvard Medical School to examine the definition of brain death. JAMA, 1968;205:337-40.
4. This number was correct as of the end of September, 1996.
5. Abraham AS, The Comprehensive Guide to Medical Halacha. (Jerusalem: Feldheim, 1990), p. 173.

Organ transplanation in India - Tharien
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