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 coordinated by the Israel National Transplant Center (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 The INTC’s responsibilities include maintaining updated 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 Brain-Respiratory 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-lobe2 A lower 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 to 49% in 2010 to 56% in 20135 (Figure 1).
Live Donation and Transplant Tourism
Another cause for low organ donation rates in Israel, both from deceased and from living donors, has been linked to the almost full reimbursement of transplant tourism by Israeli Health Insurers. Of note, this reimbursement of transplant tourists was motivated by the desire to help patients in need and was provided irrespective of the legality of the process in the distant destination due to lack of any legal restrains. Thus, in the early 2000s, renal transplantations performed through transplant tourism exceeded overall numbers of kidney transplants performed in Israel.6,7
In March 2008, 1 month before the Declaration of Istanbul against organ trafficking and transplant tourism has been formalized and signed by representatives of 78 countries around the world,8 the Israeli Parliament adopted the Organ Transplant law that follows the principles of the Declaration almost verbatim, thus changing transplant tourism originating from Israel entirely.9 The law defines selling or brokering of organs as a criminal offence punishable by 3 years in prison, in addition to a large fine, and independent if trafficking is performed within or outside of Israel. In addition, the law bans any reimbursement of organ transplantation performed abroad if it involved illegal organ procurement or trade. Because of the implementation of the law, annual numbers of patients undergoing kidney transplantation abroad have dramatically declined from 155 in 2006 to 43 in 2013,5 and the travel of Israeli patients to despicable organ markets like China10 or illegal destinations like the Philippines11 has totally ceased (Figure 2).
To increase live organ donation within Israel, the Organ Transplant Law has removed several financial disincentives for live donation by providing earning loss reimbursement of 40 days, based on the donor’s average income during the 3 months before donation; reimbursement for transportation covering all commuting to and from the hospital for the entire hospitalization and follow-up period; reimbursement for 7 days of recovery in a recuperation facility within 3 months after donation; 5 years reimbursement of medical, work capability loss, and life insurances; and reimbursement of up to 5 psychological consultations. As a result, a marked increase in live kidney transplantation has been observed.5,7 Of note, up to 30% live donors are altruistic, mostly originating from Jewish religious groups (Figure 3).
Currently, the INTC is working on the initiation of a donation after circulatory death program, in addition to seeking participation in exchange kidney programs within European countries, while developing programs to remove religious and cultural impediments for organ donation within different ethnic groups. These activities include training courses in organ donation for Jewish and Muslim religious leaders while working on a Parliament support and advocate group of joint Jewish and Muslim members.
In summary, cultural and religious barriers have been associated with low organ donation rates in Israel. The INTC and the Ministry of Health undertook several measures to improve donation, of which the most significant one was the legislative initiative of the Israel Organ Transplant Law 2008. This law embraces principles of the Declaration of Istanbul, outlawing organ trade and trafficking. At the same time, unique measures have been implemented, aiming at increasing deceased organ donation while removing disincentives for living donation.
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