Kidneys, Cash and Caring

Over recent years, “Israelis have played a disproportionate role” in organ trafficking, The New York Times reported recently in a lengthy front-page story. Some Israeli entrepreneurs “have pocketed enormous sums for arranging overseas transplants for patients who are paired with foreign donors,” according to court filings and government documents.

The organs in question are kidneys.  Most of us are born with two, although only one is necessary for living a normal life. Numerous people in renal failure have received kidneys donated by friends or relatives — even altruistic strangers.

But the supply of transplantable organs is estimated by the World Health Organization to meet no more than a 10th of the need. And so a market for kidneys has emerged, and thousands of patients receive illicit transplants each year, often facilitated by brokers, like the accused Israelis, who match potential donors wishing to sell one of their kidneys to someone who desperately needs one. The brokers maintain that they operate legally and are simply engaged in facilitating legitimate business transactions.

The unaddressed but poignant question here, though, is why the sale of kidneys is so widely perceived as immoral.  Opponents of such sales say that since poor people, likely from third-world countries, will be those most likely willing to exchange one of their kidneys for cash, embracing such activity would amount to exploitation of the poor.

Others counter that providing impoverished people with a means of garnering the sort of funds that they would otherwise have no other option of amassing would allow them to use the income to escape the poverty cycle, by investing in businesses or other enterprises. Encouraging kidney selling, these proponents say, will not only save countless lives but represents a humane way to narrow the global gap between the haves and have-nots.

In fact, while global health organizations stand steadfast against the sale of kidneys, legalizing commercial donation is no longer the fringe position it once was. The American Society of Transplantation and the American Society of Transplant Surgeons have called for pilot projects to test incentives for donation, potentially including cash payments, even though such a change would require amending a 30-year-old federal law.

That larger issue aside, though, what accounts for “the tiny nation” of Israel’s “outsize role in the global organ trade?”  The story suggests it is the result of “religious objections … to recovering organs from brain-dead patients.”

That is likely true. In other countries, organs, overwhelmingly, are retrieved from the recently deceased, declared so because they lack electrical activity in their brains but who may still be breathing with the aid of a respirator. In Israel, however, “religious objections” to equating lack of discernible brain function with death have resulted in a “severe” shortage of kidneys for transplantation.

The concept of accepting brain death as the equivalent of death has been embraced by modern medicine since the 1960s, but not by some of the past decade’s most widely respected poskim in the world — including Harav Shlomo Zalman Auerbach, Harav Yosef Sholom Elyashiv, Harav Aharon Soloveichik (who reported that his brother, Harav Yosef Dov Soloveichik, held the same position) and Harav Eliezer Waldenberg, zecher tzaddikim liv’rocho.

The brain death standard, though, has been a boon for transplantation. A person declared dead but still breathing and circulating blood, is an ideal “host” from whom to “harvest” organs.

Even among those who accept a brain-death definition of death, though, some fear that, eager to procure organs, overzealous doctors may be tempted to prematurely declare deaths to have occurred.   As for those who respect the decisions of the above-mentioned poskim that brain death does not mean life has ended, harvesting vital organs from a brain-dead patient is no less than murder.

Saving a life is a most weighty imperative, of course, but halachah does not permit one life to be taken to save the life of another — no matter how diminished the “quality” of the life of the former, no matter how great the potential of the life of the latter. Halachah, moreover, forbids any action that might hasten death, including the death of a person in extremis.

Contrary to what Reform and secular activists like to insinuate, the great majority of Israelis, whether or not they lead strictly observant lives, in fact recognize the importance of halachic concepts, particularly in matters of life and death.  And so it is not outlandish to imagine that rejection of the brain death criterion may indeed have much to do with the chronic kidney shortage in Israel.

What is unremarked upon, though, in the long Times story, is something that can be gleaned from an accompanying chart that lists 14 developed countries, ranked in order of their per capita kidney donations from donors who have been declared deceased. The country with the fewest such donors is Israel.

But also, pardon the pun, harvestable with a bit of effort from the chart, are the rankings of those same countries with regard to kidney donations by living donors, and they are telling. There, high up, above places like Canada, Switzerland, Italy, Germany and Spain, is Israel.