An article published Online First and in The Lancet reports that a unique new law comes into effect in Israel in January 2010. It states that people who are prepared to sign donor cards themselves receive priority when they are in need of an organ transplant. In addition, increased priority is given to first degree relatives of those who have signed donor cards, to first degree relatives of those who have died and given organs, and to live donors of a kidney, liver lobe or lung lobe who have donated for as yet undesignated recipients. The article is the work of Professor Jacob Lavee, Director of the Heart Transplantation Unit, Sheba Medical Centre, Ramat Gan, and the Israel Transplant Centre, and colleagues.

When considering organ donation, Israel has a bad record. Only 10 percent of adults hold donor cards, compared to more than 30 percent in many Western countries. The consent rate for organ donation is defined as the proportion of actual donors of total number of medically eligible brain-dead donors. In Israel it has consistently been 45 percent during the past decade, much lower than the 70 to 90 percent consent rate in most western countries.

During 2006, the Israel National Transplant Council (INTC) established a special committee because of these bleak national statistics. It was made up of ethicists, philosophers, lawyers, representatives of the main religions, transplant doctors, surgeons, and co-ordinators. After long discussions, they recommended to the INTC that any candidate for a transplant who had a donor card for at least three years before being listed as a candidate will be given priority in organ allocation. Similar priority will be granted to transplant candidates with a first-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.

New legislation was needed since this meant using non-medical criteria in the organ allocation process. The Israeli law has increased the number of beneficiaries for organ allocation from the signatory on the donor card to the first-degree relatives such as 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 the number of beneficiaries was reduced by excluding live donors of kidneys, liver lobes or lung lobes who donate their organs to a designated relative. The authors remark: "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."

There are different levels of priority concerning the different situations. A transplant candidate with a first-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. Then again, a transplant candidate with a first-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 the same number of allocation points, organs will be allocated first to prioritisation-eligible candidates.

Regardless of the new law, patients in urgent need of a heart, lung, or liver transplant due to their serious condition will continue to receive priority. However, in the event that two such people are eligible for the same organ, their priority status under the new law would decide who receives the organ. Candidates under 18 and those unable to express their wishes due to physical or mental disability will retain their priority status versus an adult who merits priority.

A massive public information campaign, in multiple languages and formats, is ongoing in order to educate the Israeli population on the new law.

The authors explain: "The Israeli policy applies to everyone with no exemptions, even to people who believe they should not donate organs because of religious beliefs11 or deeply held philosophical convictions. The observances and rituals of a religion are not incumbent on people of a different faith; however, the morality of a religion, in the opinions of its adherents, should be universal. True believers in the immorality of organ donation after brain death would not be affected by this policy because if organ donation after brain death is wrong, then it should also be wrong for their potential organ donors and hence they should not give or accept an organ."

They write in conclusion: "The effect of the new policy on organ donation will be monitored and a public report will be issued 2 years after implementation. If this new policy achieves the goal of obtaining more organs, everyone will benefit and people who do not sign a donor card, though disadvantaged, will nonetheless be better off than they would have been without the policy. If undesirable consequences emerge, such as no increase in organ donation, or an increase in candidates' mortality rates, then policy and legal adjustments will be necessary."

In an associated note, Linda Wright, University Health Network, Toronto, and University of Toronto, Canada, and Diego S Silva, University of Toronto Joint Centre for Bioethics, Canada, remark regarding the restriction in the new law: "Because the rise in donation rates in some countries during the past decade has partly been due to the increase in living donors, should we not be increasing our support for living donation?"

In conclusion, they also stress the importance of the public information campaign: "If Israel's initiative of incentives for donation actually makes a difference by producing more organs for transplantation, it will be instructive. We wait to see."

In a second note, Dr Paolo Bruzzone, Department "Paride Stefanini" of Surgery, Surgical Sciences and Transplantation, Umberto I° Policlinico di Roma, Sapienza Università di Roma, Rome, Italy, comments: "Certainly, giving holders of donor cards priority in organ allocation sounds more acceptable than the introduction of organ conscription (ie, the proposed forced removal of organs from brain-dead patients without previous consent from the donor when still alive or from relatives) or financial incentives for organ donation (such as payment for funerals or tax incentives in cases of cadaveric organ donation or some financial reward in cases of living organ donation)."

"A new law for allocation of donor organs in Israel"
Jacob Lavee, Tamar Ashkenazi, Gabriel Gurman, David Steinberg
DOI: 10.1016/S0140-6736(09)61795-5
The Lancet
Written by Stephanie Brunner (B.A.)