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A clash of religion and bioethics complicates organ donation in Israel

JERUSALEM – In the Book of Genesis, it is written that when the great flood submerged the land, the flood extinguished “all in whose nostrils was the breath of life.” Across nearly 2,000 years of Talmudic debate, Jewish scholars have returned to that verse in holding that life ends at the moment when breathing stops. One 19th-century code instructed that if a person appeared lifeless, a light feather was to be placed before his nose: “If it does not flutter,” the text advised, “he is certainly dead.”

The sages could not have anticipated that their writings would provide the underpinnings for cultural resistance to organ donation from the deceased in 21st-century Israel. But that definition of mortality, which can conflict with modern acceptance of brain death, is cited among several reasons Israel has among the lowest rates of deceased organ donation of any developed country.

The resulting five-year waits for a kidney from a cadaver help explain why this tiny nation has played an outsized role in the global organ trade, experts say.

Since 2000, one trafficking prosecution after the next has implicated Israelis. Although recent legal changes have made it less enticing for Israelis to seek transplants overseas, the new laws have contributed to longer wait lists at home, and that has kept organ brokers in business.

“The continued driving force is the lack of deceased donation in Israel and the concept that every rich person worldwide would rather put a stranger at risk than a relative,” said Dr. Jeremy R. Chapman, an Australian nephrologist and past president of the Transplantation Society.

Despite its advanced medical infrastructure, Israel trails comparable countries in most measures of organ donation. In 2012, Israel had 7.4 deceased donors per million population, ranking it in the bottom third of countries surveyed by the Council of Europe. The rate was 18.5 in Britain, 25.8 in the United States and 35.1 in Spain.

About 15 percent of Israeli adults are registered as donors, according to the Health Ministry’s National Transplant Center, compared with nearly half of adults in the United States.

“If someone is planning on going through a transplant, waiting to get a kidney in the country, there is a greater chance that the Messiah will come,” said Amos Canaf, founder of an Israeli advocacy group for renal patients.

Opposition to organ donation from the deceased runs contrary to both government policy and pronouncements of the chief rabbinate, but has been embraced by a core of ultra-Orthodox rabbis with trickle-down influence.

Although many Israelis are secular, even nonreligious Jews grasp for the faith’s instructions at the end of life. “At times of death and mourning, a person remembers his roots,” said Rabbi Shlomo Amar, a former Sephardic chief rabbi who accepts the brain-death definition.

The collision of ancient theology and modern bioethics reached its apotheosis with the high-profile case of Avi Cohen, an Israeli soccer legend who was declared brain dead after a motorcycle accident in 2010. Informed that Cohen, 54, was a registered donor, his family initially granted permission to recover his organs. As a matter of practice, hospitals in Israel will not proceed without a family’s consent.

But with his breathing maintained by a ventilator, Cohen appeared lifelike. His devastated wife and children could not drown out the voices of visitors to his bedside who cautioned he might still revive.

“We wanted to believe in anything,” recalled Dorit Cohen, Avi Cohen’s widow. “To take the last step and end his life is something I could not do.”

Today, she regrets her reversal. “Avi would do anything to help people,” she said. “I’m sure he would not have agreed with my decision.”

Among the religious obstacles to donation is a belief by some traditional Jews in physical resurrection and a conviction that the body should not be desecrated before burial. Physicians and ethicists also remark on a cultural resistance to asking relatives to donate. For years, state policy essentially supported transplant tourism by allowing insurers to reimburse patients who went overseas.