A new law for allocation of donor organs in Israel.

Israel’s system for organ donation has been based, since its inception in 1968, on a model in which organs for transplantation are retrieved from brain-dead donors only after consent has been obtained from the appropriate fi rst-degree relatives. This consent is needed even if the potential donor has expressed a wish for posthumous organ donation by signing a donor card, which is a government form that allows people to voluntarily indicate their wish to donate specifi ed organs after their death. The consent rate for organ donation in Israel, defi ned as the proportion of actual donors of total number of medically eligible brain-dead donors, has consistently been 45% during the past decade, much lower than in most western countries. Similarly, the proportion of adults with donor cards in Israel is only 10%. In January, 2008, 864 candidates were listed for kidney, heart, lung, or liver transplantation, but only 221 patients were given transplants from deceased donors that year. In two formal surveys of public attitudes towards organ donation, which were done by the Israel National Transplant Centre in 1999 (n=758) and 2004 (n=417), 55% of individuals in each survey indicated their willingness to donate organs in exchange for prioritisation in organ allocation. In both surveys, the proportion of individuals who chose this option was much greater than the proportions choosing the second and third preferred options, which were direct (26%) or indirect fi nancial compensation (25%), respectively, for organ donation. The basis of this public reaction is mainly a perceived need to rectify the unfairness of free riders—people who are willing to accept an organ but refuse to donate one—as practised by a small yet prominent proportion of the Israeli public. These individuals are opposed to the idea of brain death and organ donation, yet they do not abstain from becoming candidates for transplantation when they need an organ for themselves. The results of the surveys of attitudes of Israeli people resemble those noted in similar surveys done in the USA in 1990 and 2004, in which 52% and 53% of responders, respectively, ranked a preferred status in organ allocation as their top-ranked option for compensation for organ donation. With the grim national statistics for organ donation, and the knowledge that relatives of potential donors who were holders of donor cards have consistently given their consent for organ donation, a national plan for prioritisation of organ allocation was devised to increase the number of individuals with donor cards in the hope that such an increase would lead to an increase in organ donation. The plan to increase the national number of individuals who have a donor card by giving priority in organ allocation to transplant candidates who had signed a donor card before their listing date was fi rst suggested to the Israel National Transplant Council (INTC) in March, 2006. This council established a special interdisciplinary committee—inclu ding leading ethicists, philosophers, legal advisers, representatives of the main religions, transplant physicians, surgeons, and coordinators—to review the various relevant ethical, legal, medical, and social issues. After long discussions, the committee recommended to the INTC that any candidate for a transplant who had a donor card for at least 3 years before being listed as a candidate will be given priority in organ allocation. Similar priority will be granted to transplant candidates with a fi rst-degree relative who was a deceased organ donor and to any live donor of a kidney, liver lobe, or lung lobe who subsequently needs an organ. Because the new plan includes, for the fi rst time, implementation of non-medical criteria in organ allocation, legal advisers said the policy could not be implemented by administrative rules and required legislation by the Israeli Parliament. After the approval of these recommendations by the INTC, the Ministry of Health has asked Israel’s Parliament to incorporate the prioritisation plan into the new bill for organ transplantation. After a long debate within the Israeli Parliament, clause 9(B)4 was added to the recently approved law for organ transplantation (panel). The Israeli law has increased the number of benefi ciaries for organ allocation from the signatory on the donor card to the fi rst-degree relatives (parents, children, sibling, or spouse) on the basis of past experience, whereby relatives who were holders of the card had always given their consent to organ donation even if the donor did not sign it, yet reduced the number of benefi ciaries by excluding living-directed donors. This restriction, which contradicts the INTC’s original recommendation, is being prepared by the Ministry of Health for an appeal for reconsideration by Parliament, because we strongly believe all living donors should be granted prioritisation in organ allocation. On the basis of a new law, the steering committee for Israel’s National Transplant Centre decided to set up three allocation priority categories with diff erent levels for each transplanted organ (table). On the one hand, a transplant candidate with a fi rst-degree relative who has signed a donor card would be given half the allocation priority that is given to a transplant candidate who has signed his or her own donor card. On the other hand, a transplant candidate with a fi rst-degree relative who donated organs after death or who was an eligible live non-directed organ donor would be given allocation priority 1·5 times greater than that given to candidates who have signed their own donor cards. Among candidates with an equal number of allocation points, organs will be allocated fi rst to prioritisation-eligible candidates. Published Online December 17, 2009 DOI:10.1016/S01406736(09)61795-5