In the US, 18 patients on the organ waiting list die each day. The US, like every other country except Iran, relies on a non-commercial or altruistic system in which organs must be donated (either from living or recently deceased individuals), rather than for-profit. The US has an opt-in system in which people must elect to be a donor. Places such as Spain and Austria have selected the opt-out system: people must request not to be a donor. The waiting list in these places is shorter and people do get kidneys and livers sooner, but not significantly. It is assumed that in places such as Spain and Austria that most patients who die on the waiting list are themselves willing to donate an organ. Israel is trying a new approach wherein it prioritizes transplant patients who, themselves, have agreed to donate their organs. In so doing, Israel has become the first country in the world to incorporate “nonmedical” criteria into the priority system, though medical necessity would still constitute the top priority.
According to Jewish law, desecration of the dead is prohibited, which has been interpreted by many circles, primarily ultra-Orthodox, to mean that Judaism prohibits organ donation. Jewish law however also ascribes that saving a life is the highest value and obligation, and as such most Jews justify organ donation on those terms. The motivation behind Israel’s rule is to prevent those who would not donate but would receive organs from receiving them ahead of others who are willing to donate their organs. As medical necessity still outranks personal views, the law would only apply when two people with identical medical needs need the same organ: the recipient, then, is the willing donor.
At face value this new system seems pretty fair: why should someone unwilling to donate his own kidney receive a kidney, one which would equally benefit another person in need– a person who is also willing to give? There are, however, a number of troubling concerns about this system. First, there is a worry of religious discrimination. Should we base medical decisions on an individual’s religious observances? It’s not clear whether religious belief comes from a place of free choice to believe in organ donation or my very obligation to the idea in my religion that saving lives is paramount. An ultra-Orthodox Jew who does not believe in organ donation, does so on the basis of an obligation to the laws of Judaism, obligations seen as something required from us rather than something we voluntarily elect to adopt. While I freely choose to pay my taxes, my overwhelming motivating force is that I am obligated to do so. Is it possible to claim that those who do not believe in organ donation do not do so because they choose to submit to an ideology in which that is the perspective, or rather they are compelled to? The moral implications of this answer are significant: one who feels compelled seems to be less responsible for his beliefs and therefore less culpable for the repercussions, namely being denied priority on that basis.
Second, there is a concern of coercion. An individual could opt-in or choose not to opt-out of the organ donation system because she knows that could potentially lose the opportunity for a liver that she herself needs. Let’s say then that the situation arrives in which her kidney is a good match for another (not really sure if that would happen considering she needs a liver, but hypothetical situations are fun for the exact reason that they are hypothetical). Although she is a match and has opted in to the system, she has done so out of fear that she herself will not receive a liver. Can such an individual be considered to be giving her kidney freely and willingly, from a place of true compliance, something many hold as prerequisite to organ donation in general? The answer seems to be that she is not, which means that her organ donation has been coerced.
Third, such system may translate to other realms of the medical world, such as blood donation. I know many people who are very squeamish around needles, faint each time they donate blood, and/or are repulsed by the sight of the substance. It seems wrong to deny a person a blood transfusion because they themselves have not donated blood, even if it is not for any of the aforementioned reasons. Should we start a blood donor registry in order to know when someone is injured and loses lots of blood or is wheeled into surgery, whether or not that person should receive blood? Furthermore, what if he’s only given blood once? Can he only receive 2 pints of blood?
There are, as with many medical laws, pros and cons to this particular organ donation system. I hope that ethicists and scientists, doctors and politicians, religious authorities and secular leaders alike can figure out a perfect algorithm that maximizes life protection and minimizes rights violations.
By: Naomi Scheinerman
(Photo by matt northam under a Creative Commons license)