The liver transplantation performed on Israel's former Mossad director Meir Dagan at the Minsk transplant center in Belarus has once again brought into public spotlight the shortage of organ donations and its consequent transplant tourism.
For years Israel has been slandered as a country which exports many of its candidates for organ transplantation to countries in which organ trade is common. Israel has not been the only country exporting transplant tourism, but it has been unique in that its patients were the only patients who were almost fully reimbursed for their transplant operations by their insurance companies or sick funds. This reimbursement of transplants was granted regardless of the legal status of these operations or whether they involved organ trade.
An extreme and notorious example has always been the transplant tourism of Israeli patients to China, a country in which the main source of transplanted organs has always been and still is prisoners convicted to death by the Supreme Court or citizens executed after being accused as dissidents. The reimbursement provided for those organ transplantations in the Israeli patients has been considered as a semi-formal endorsement of an activity which has been uniformly denounced by any international institute as representing a crime against humanity.
In 2008, one month before the international Declaration against organ trade was signed in Istanbul, the Knesset passed the Organ Transplant law, which conforms to all the principles of the Declaration. The law defines precisely the circumstances of organ trade and trafficking and declares the buying, selling or brokerage in organs as a criminal offence punishable by three years in jail together with a large fine, whether performed within or outside Israel. It clearly bans the reimbursement of organ transplantation anywhere outside of Israel if the procurement of the organ and its transplantation has been performed contrary to the law of that country and if stipulations of the Israeli law regarding organ trade are contravened.
Orders banning insurance companies and sick funds from reimbursing illegal transplant tourism went into effect shortly after the new law has been enacted, which brought transplant tourism of Israeli patients to illegal venues where organ trade took place to a halt. Thus, for example, the traveling of Israeli patients to China has stopped completely ever since. This use of the law against organ trade has brought praises upon Israel and is repeatedly cited in international forums as a remarkable example of national recruitment against organ trade.
High level Israeli medicine
In parallel to banning organ trade and illegal transplant tourism, the law includes unique clauses aimed at increasing the number of locally donated organs from live and deceased donors. The law promotes legally authorized altruistic live organ donation by removing some financial disincentives which have always hampered live donation, such as reimbursing for work loss or various life and health insurances. The implementation of these measures has already resulted in a significant increase in live kidney donations from 71 cases in 2010 to 117 cases in 2012.
The law also promotes deceased organ donation by a world-unique clause which grants candidates for organ transplantation priority in organ allocation if they have been registered donors for at least three years prior to being listed or if their immediate family has given its consent for organ donation of their deceased beloved one. This prioritization policy has been implemented as of April this year, but its impact has already been evident last year, following the public campaign which preceded its implementation. The number of registered donors has increased significantly and was joined by a significant increase in the consent rate for deceased organ donation from 49% in 2010 to 55% in 2011.
The apparent positive trend in organ donation in Israel following the implementation of the new law is good news to the one thousand candidates for organ transplantation but it is far from being satisfactory. The number of candidates for organ transplantations always far exceeds the number of donated organs anywhere in the world and therefore strictly defined medical and social criteria of organ allocation are always needed in order to ration the limited supply. Thus, for example, in many countries an upper age limit of 65 has been set for accepting new candidates for heart or liver transplantation. This age limit is based not only on the scarcity of donated organs but also upon the diminished short and long term results of transplants performed beyond this age limit.
The Declaration of Istanbul has set all nations the goal of becoming self-sufficient by maximizing the potential of deceased and living organ donations. Neither the Declaration nor the Israeli law ban cooperation between countries towards assisting individual patients' problems in case these cannot be resolved within their own country, such as in the case of Meir Dagan, on condition that such cooperation will not significantly compromise the rights of the citizens of the country providing the help to receive proper transplant services.
In this spirit many countries have implemented rules which grant a very small percentage of their deceased donated organs to be allocated to foreign transplant candidates. An essential condition to such legal transplant tourism would be a total ban on any form of deceased organ trade and reassuring that the revenues from this process will never be diverted towards purchasing the organ.
The more we utilize to the fullest the local potential of organ donations both from deceased and from living donors, the less will be the need of our candidates for organ transplantations to seek foreign destinations and we will be able to save their lives locally, close to their families and loved ones, while enjoying the high level of Israeli medicine.
Prof. Jacob (Jay) Lavee is the director of the Heart Transplantation Unit at the Sheba Medical center, chairman of the Heart and Lung Transplantation Committee of the Israel National Transplant Center and Israel’s representative at the international Declaration of Istanbul Custodian Group.