Letter: Reciprocal Altruism Does Not Underlie Israeli Organ Transplant Law

[Clark]

http://onlinelibrary.wiley.com/doi/10.1111/ajt.12241/full

Reciprocal Altruism Does Not Underlie Israeli Organ Transplant Law
D. Shabtai
DOI: 10.1111/ajt.12241
American Journal of Transplantation
Early View (Online Version of Record published before inclusion in an issue)

To the Editor:

The authors' report of increasing availability of transplantable organs in Israel [1] is noteworthy and encouraging; they attribute this rise to the recently passed Organ Transplantation Law. However, even while achieving such noble goals, this law cannot be rightly justified as predicated upon the notion of reciprocal altruism, as the authors claim it to be.

Signing a donor card is not an altruistic action per se, since Israeli law mandates that the actual donation depend upon the consent of the donor's proxy or next of kin and cannot be undertaken without their approval [2]. But even if considered to be altruistic, it should rightly be attributed to the donor. The law however, assigns transplant priority even to first degree relatives of a deceased organ donor. While the original donation was motivated by a sense of altruism—it was the altruism of the donor himself or herself, not their first degree relatives. Assigning transplant priority status to these relatives does not reflect reciprocity, but rather appears to incentivize these relatives to agree to the donation in the first place.

Additionally, the law completely disregards the continued care of live directed kidney donors, even as the authors note an increase in such donations. The United Network for Organ Sharing advocates a policy of giving living organ donors priority in receiving a transplant themselves should they ever need one, which the authors cite as a paradigmatic model for organ allocation. The Israeli law however, specifically excludes the vast majority of live organ donors from any transplant priority, should they themselves ever require an organ transplant [3]. Oddly, the Israeli law assigns transplant priority only to live organ donors to unspecified recipients, excluding most live donors, who are indeed aware of the designated recipients of their organs.

While donations from deceased donors are indeed laudable and certainly require a sense of altruism and commitment, for the donor himself or herself the “sacrifice” is not so great. The donor suffers no consequences from the donation and the organ recovery entails no risks. Nonetheless, the law recognizes the strength of principle and beneficent altruism entailed.

Living directed organ donation strides above and beyond these notions. These donations are undertaken by individuals, who are willing to give of themselves—both figuratively and literally—to save someone they know. As the new law prohibits almost all types of compensation (with the notable exception of transplant priority), these donations display pure altruism in perhaps its most pristine form. Should a live organ donor—who consciously and willingly donates an essential organ and must live with the consequences of his or her choice—deserve less than a relative of a deceased donor?

With this law in place, it does indeed appear that more lives will be saved. However, in justifying the ends, we must never neglect our duty to objectively analyze the means. Changes to the law, reflecting true justice and more robust justification, are indeed in order.

D. Shabtai