Prioritization for Organ Allocation

Rewarding Reciprocity: The Ethical Implications of Organ Allocation

By Sophia Brandstaedter

This research paper explores the ethical implications of organ allocation. Due to an organ shortage crisis, where the number of organs needed exceeds the number of organs donated, each country has developed a policy determining who gets priority for receiving this scarce resource. This paper will compare the systems of prioritization in the U.S. and Israel. In the U.S., the sickest patients are prioritized for transplant. The U.S. has one of the highest rates of organ donation in the world, while Israel has one of the lowest rates of organ donation among developed countries. In an effort to raise organ donation rates, Israel passed the Organ Transplant Act giving priority to registered organ donors, living donors, or individuals with a relative that was a deceased donor.

Table of Contents

• Abstract
• Factual Background
• Organ Transplant Prioritization in the U.S.
• Organ Transplant Prioritization in Israel
• Overview of Prioritization Models of Organ Allocation
• Justice
• Utility
• Conclusion

In 1954, the first successful human organ transplant was carried out at a hospital in the United States of America. Now, there are hundreds of organ transplants around the world every day. However, the number of needed transplants has long exceeded the number of available organs. For this reason, each country has developed policies pertaining to who gets priority in receiving an organ. When dealing with such a scarce resource, all countries aim to increase utility, while maintaining a fair and equitable process. In the United States of America, those deemed to be the sickest are prioritized on the organ transplant waiting list. Other factors, such as geography and compatibility of the donor organ and recipient, are also taken into account. On the other hand, in multiple countries including Israel, those who have been registered organ donors, living organ donors, or have a relative who was a deceased organ donor receive extra priority points. This is a system of reciprocal altruism, where people help others in society while helping themselves. Both the U.S. and Israel use the prioritarian model, a system in favor of giving organs to those who are suffering the most, as both countries first assess medical urgency for organ transplants, and prioritize those individuals. Then, the utilitarian model plays a role as it aims to save the most lives with the valuable resource of an organ (Petrini). There are flaws within each of these systems, though, such as the fact that it is difficult to rank patients based on level of sickness, as well as issues with justice and equity in Israel’s prioritization system. Both systems attempt to balance utility, justice, and equity. However, the application of these values looks different in each country, as the system in the U.S. does this by giving an equal evaluation of all transplant candidates, and Israel awards priority points to individuals who donate or are willing to donate their organs. 

This paper focuses on the ethical implications of both of these prioritization systems and specifically looks at the values of utility, justice, and equity when comparing the two. So, what is the most ethical method of organ allocation and is it ethical to prioritize the allocation of organs based on reciprocity?

Organ transplantation has been on the rise for decades all around the world. This is in part due to the increased incidence of vital organ failure and improvement in post-transplant outcomes. In addition, increased life expectancy has led to a greater number of people being put on the transplant waiting list at some point in their lives (Abouna). Many countries are now facing an organ shortage crisis preventing many people from receiving organ transplants, and therefore, often having to opt for more expensive medical care. Now, each country is attempting to maximize the number of organs transplanted and the number of people who benefit. 

As of 2022, over 100,000 individuals in the United States are on the national organ transplant waiting list. In 2021, there were around 20,000 deceased and living organ donors and 40,000 transplants. Over 169 million people are registered organ donors, which is about 58 percent of Americans (UNOS). 

Looking at statistics in Israel, there are currently approximately 1,200 people on the organ transplant waiting list. In the last year, approximately 600 transplants were performed (Gov.il). There are currently 823,264 registered organ donors, which is 14 percent of the adult population. Deceased donation rates are significantly less in Israel than in the U.S. while its living donation rates are comparable. With these statistics, organ donation rates in Israel are among the lowest of the developed countries (The Observatorial).

Both the U.S. and Israel have opt-in systems of organ donation, where one must express their preferences for being a deceased organ donor, and no one is presumed to be a willing donor. This means that in order to be an organ donor, one must opt-in on the organ donor registry. In opt-out countries, there is presumed consent for organ donation of the deceased unless the individual has opted-out. There are both soft opt-out systems, where the family is involved if their relative has not opted-in or opted-out, as well as hard opt-out systems, where the family has no role, even if their relative is not registered. Although more countries are beginning to switch from opt-in to opt-out policies, the U.S. and Israel remain opt-in. In the U.S., one can register to be an organ donor online or at their local motor vehicle department (Donor Network West). Similarly in Israel, one can sign up to be a registered organ donor online or at service stands across the country. 

In the U.S., 95 percent are in favor of being an organ donor, but only 58 percent of the population is registered. One factor contributing to this discrepancy is the common misconception that doctors will not work as hard to save a life if they see that the person is a registered organ donor. Many people also are unsure about whether their religion supports organ donation, but assume that it does not. In reality, all major religions do support organ donation, though. In Israel, however, only 14 percent of the population are registered organ donors. This difference is one of the main reasons Israel decided to give extra priority to registered organ donors, hoping to increase the number of people that hold donor cards. They also aimed to increase family consent rates, which would increase the overall donation rates. The U.S. still has a big gap between the number of transplants needed and organs donated, though, so what is the best system of organ allocation?

Although organ transplants were being performed in the U.S. since the 1950s, the government was not involved until the late 1960s. At this time, the number of transplants performed was on the rise, and because Medicare and Medicaid were paying for many of them, the government stepped in. The Uniform Anatomical Gift Act of 1968 set a legal foundation for organ procurement and donation. This act also created the donor registration system, where people could register to be organ donors at a Department of Motor Vehicles in their state. In 1984, the National Organ Transplant Act (NOTA) established a task force to study transplant issues and provided grants for organ procurement organizations (OPOs), which led to the creation of the Organ Procurement and Transplantation Network (OPTN). An amendment was added to NOTA in 1988 stating that “the OPTN should resolve any issues regarding the fair and effective distribution of organs. Patient welfare must be the paramount consideration.” Another amendment to NOTA followed in 1990, reaffirming OPTN to “assist OPOs in the nationwide distribution of organs equitably among transplant patients.” These acts and amendments set the foundation for organ transplantation in the U.S., but have gone through changes as the demand for organ transplants has increased.

In 1998, the Department of Health and Human Services (HHS) put out a new regulation for the OPTN and the United Network for Organ Sharing (UNOS). This new regulation stated that the OPTN is to “allocate organs among transplant candidates in order of decreasing medical urgency status” and that place of residence would not be a major determinant of access to a transplant. The HHS final rule also stated that waiting time in status should be used to break ties within status groups. Soon after this regulation was put into place, members of the American Society of Transplant Surgeons testified before Congress saying, “giving priority to the sickest patients first over broad geographic areas would be wasteful and dangerous, resulting in fewer patients transplanted, increased death rates, increased retransplantation due to poor organ function, and increased overall cost of transplantation.” These are the main laws and regulations that have contributed to the current system of organ allocation.

Today, the OPTN takes many factors into account in the allocation of organs. The three main considerations when generating a composite allocation score are compatibility of the donor and recipient, geography, and medical urgency. First, a transplant candidate must be screened to see if their blood type, height, weight, and other medical factors are compatible with the possible donor. The other medical factors depend on the type of organ. Interestingly, kidneys are the only organ in the U.S. where the fact of one being a prior living donor is taken into consideration due to the increased risk of health complications (Tan). Then, geography plays a role. In the U.S., there are 57 local Donation Service Areas and 11 regions used for organ allocation. If an organ has less time to be transplanted, like a heart or lung, a radius from the donor hospital instead of the region may be used. Lastly, the most medically urgent patients are prioritized for transplant (U.S. Department of Human and Health Services). 

UNOS, created by Congress, is an organization outside of government, and is responsible for making decisions pertaining to organ allocation. UNOS members are patients, transplant recipients, representatives of health, medical, and scientific organizations, transplant centers, and more. Their responsibilities include measuring the medical status of patients waiting for organ transplantation and altering organ allocation policies to optimize benefits for organ transplant recipients (Van Meter). 

The system of organ allocation in the U.S. is considered a prioritarian system, as it favors giving organs to those who are suffering the most. This system also attempts to provide equal consideration to justice, which refers to the fair and equitable distribution of health resources, and utility, or bringing about the greatest amount of benefit to as many people. Justice is given to the most medically urgent patients as organs are allocated first to the sickest patients.  Then, utility comes into play as the system attempts to efficiently use organs. However, these two values can conflict in some instances. For example, in some cases, hospitals will allow transplantation for some of the less urgent patients that have a higher probability of surviving the longest and not needing a second transplant.

However, there are many flaws within the system. First, it is difficult to measure medical urgency, so instead medical urgency is measured by intensity of treatments. Therefore, patients receiving more, stronger treatments will be prioritized. This has become an issue because some hospitals over treat patients to boost their ranking on the organ transplant waiting list. This could lead to patients able to afford and receive strong treatments being prioritized, rather than the sickest patients. Transplant centers are also scored on patient survival rates after one year. So, some centers prioritize patients they believe will have the easiest recovery, often not the sickest patients, in order to raise how the transplant center is scored and ranked (Wood). 

With geography now taken into consideration, some patients are at a disadvantage and have a much smaller chance of receiving an organ because of where they live. A study shows that people on the liver transplant waiting list are 30 percent less likely to receive an organ if they live in an urban area (Vladeck). Ever since the HHS Final Rule, there have been concerns about geographical disparities with organ allocation, and attempts to make the system more equitable. For example, the borders of donation regions are often disputed and redrawn in an effort to decrease the geographical inequalities. However, there is little evidence that suggests this issue has been solved. OPTN has tried to reduce the effect of geography in determining a candidates’ chance of receiving an organ transplant and have implemented broader organ sharing to reduce geographical disparities (Salvalaggio). 

Although the system has its flaws, the OPTN and UNOS aim to have a fair and equal evaluation of all transplant candidates. It is difficult to implement a perfectly equitable system, as there is no standard way to measure medical urgency and transplant centers must be scored in some way. Is there a solution to creating a system that is fair and not susceptible to manipulation? In addition, the U.S. is one of the largest countries in the world in terms of both area and population. This makes it difficult to give everyone an equal chance at receiving an organ transplant if they live very far from a transplant center or are in a region with less organ donations.

In contrast to the U.S., Israel is behind most of the developed world in organ donation rates, so a unique organ allocation law was implemented in 2008 in an effort to raise donation rates. Israel has consistently had extremely low organ donation rates, which can partially be attributed to its large religious population. Particularly looking at the large Jewish population in Israel, some object to brain death, while other superstitious beliefs lead some to believe that becoming a registered organ donor can lead to a premature death. The rejection of the idea of brain death has to do with the belief that death is the moment when the cardiac and respiratory function stops. In addition, some sects of Judaism believe that the body should not be desecrated before burial. These religious objections are significant factors that have contributed to low organ donation rates. A possible solution to these objections is raising awareness about religious objections to organ donation, as most major religions support organ donation, but many are unaware of whether their religion does. However, education campaigns, including religious leaders speaking out about supporting organ donation, have been launched in the past, but consent rates still remain low. Because of the low donation rates, Israel had a very short supply of organs leading them to turn to transplant tourism until 2008. 

Deceased organ donation rates in Israel are very low compared to other Western countries. The main reason Israelis do not register as organ donors is based on religious objections. Israel is home to many different religions and ethnicities, including Judaism, Islam, and Christianity. Many ultra-orthodox Jews object to brain death, and therefore, are not registered organ donors. However, only 8 percent of Israel’s population is ultra-orthodox Jews who share these beliefs. Israel also has a significant Arab population, who hold their cultural and religious obstacles to organ donation.

In 2008, Israel changed the law to give priority on the organ transplant waiting list to those who have been registered organ donors at least three years before being put on the waiting list, those who have been live organ donors or have a first degree relative who has been a deceased donor. The Organ Transplantation Act removed multiple financial barriers to live donations, as reimbursements are now provided for transportation, recovery, psychological consultations. It also outlawed transplant tourism which Israel had relied on for many years prior to the law. This new Organ Transplantation Act, which came into effect in 2010, was changed as a result of the short supply of organs compared to the overwhelming need, and was an attempt to have more living and deceased organ donors. 

The new priority system has different levels of priority: maximum, regular and second. For maximum priority, one’s deceased first degree relative must have been given consent for organ donation, or one must have donated a kidney, liver lobe, or lung lobe to a non-specified recipient. If one donates to a particular recipient, they do not receive priority. For regular priority, one must hold a donor card. Lastly, for second priority, one’s first degree relative must hold a donor card.

The Organ Transplant Act in Israel is an example of the ethical principle of reciprocal altruism where people in society help each other while helping themselves. Incentivizing organ donation takes into account reciprocity, or giving and receiving. Then, organ donors who donate to unspecified recipients are considered altruistic donors, meaning selfless. Israel’s law can be seen as valuing altruistic donors very highly, as they receive maximum priority. In addition, this law attempts to get rid of “free riding” candidates for organ transplantation, where individuals will not donate organs after death because they reject brain death, but they are still willing to receive an organ. 

With the Organ Transplant Act, the Brain-Respiratory Death Act was also put into place, clearing up confusion in determining death. This law attempted to legally satisfy medical and religious requirements with a new definition of death. However, this law has been met with challenges as physicians have to undergo a voluntary training course in order to be certified to determine death, so there has been a significant decrease in the number of physicians that can determine death. New tests are now required at hospitals to determine brain death, which many did not have when the law first went into place. Both of these obstacles to declaring brain death have affected the rates of organ retrieval (Berzon).

After the Organ Transplant Act in Israel in 2008, similar laws followed in Singapore and Chile. Both of these countries introduced the priority system with an opt-out system, a contrast from Israel’s system, in an attempt to increase the number of organ donations and transplantations. Looking specifically at Chile, the Organ Donor Act was introduced in 2010, stating presumed consent for organ donation. The goal of this law was to increase organ donation rates. However, it resulted in thousands opting-out and a 15-year low of individuals who donated organs. In 2013, the law was amended to state that “those not registered as non-donors will be entitled to priority in allocation of organs for transplantation purposes.” Therefore, individuals who chose to be non-donors from 2010-2013 lost priority. As of 2015, Israel, Singapore, and Chile were the only countries to have enacted a priority system of reciprocity for organ transplantation (Zúñiga-Fajuri). These prioritization systems in Israel, Singapore, and Chile can be looked at as utilitarian systems, as they attempt to save the most lives by encouraging more organ donors.

A connection can be made between organ donor registration priority and childhood vaccination policy. If a child is vaccinated, they will likely receive a health advantage, but if much of the population is not vaccinated, disease will continue to spread. If parents choose to remain unvaccinated, they may still receive protection if vaccination rates have reached herd immunity. Comparing this to organ donor registration, if everyone or almost everyone was a registered donor, priority for this would become irrelevant, and Israel would have a very high organ donation rate.

The 2008 law has had an impact on organ donation rates in Israel. If people are asked if their deceased relative should be an organ donor, they are more likely to consent if they would be prioritized on the organ transplant list. Since the new law, family consent rates to organ donation have risen. From 2010 to 2013, consent rates rose from 49 to 56 percent, and there were a record 70,000 individuals signing donor cards. As of 2022, family consent rates are up to 61 percent. However, even with the priority system, Israel is still very behind in organ donation rates.

Many critics of the law say it is unjust because depending on the number of relatives someone has, they may have a big advantage or disadvantage in the prioritization system. For example, if one has many relatives, they will have a higher chance of receiving priority points. The law would be more just if it did not include the clause stating that first-degree relatives of deceased donors or first-degree relatives of someone who holds a donor card receive priority. Solely basing the priority points on registered organ donors or living donors would eliminate the inequalities based on the number of first-degree relatives one may have. In addition, those who do not have media or engage in public campaigns are at a disadvantage as they are less aware of the priority system. With knowledge of the priority points, they would be more likely to register to be an organ donor or consent to a relative donating after death. Those with religious beliefs that prevent access to the internet or those with low medically literacy are specifically disadvantaged in terms of knowledge.

Next, should intentions matter when discussing the ethicality of Israel’s law? The Israeli prioritization system awards those who are living donors for an unspecified recipient, but gives no priority to living donors who donate to a recipient they know. Although their intentions for organ donation may be to help a relative or friend, they still help organ donation and transplantation as a whole, as there would be one less patient in need of an organ. In addition, people may be more likely to consent to organ donation of a deceased relative if they would receive priority points, even if it goes against what they believe their relative would have wanted. Their intent for organ donation may be different, but they are still donating those organs, therefore, increasing the supply, which is the purpose of the Organ Transplant Act. One critique of Israel’s law is that there is a difference between incentives to donate one’s own organs and incentives to consent to the donation of the organs of others. In Israel, hospitals will not proceed with organ procurement from a deceased registered donor unless the family consents. So, the decision of organ donation is truly up to the family. The priority system could influence the family’s decision, and possibly lead them to a decision that differed from the wishes that their relative expressed in order to receive maximum priority. Here, the responsibility of a family member to their relative comes into conflict with an individual’s own wishes for priority points. However, in Israel, there has also never been a known case where a family consented to organ donation against their relative’s known wishes.

Lastly, there is room for manipulation within Israel’s priority system. The 2008 law prioritizes individuals who are registered organ donors for at least three years before being put on the waiting list. Individuals who know they will be excluded from organ donation because of medical reasons such as diabetes or HIV may still sign donor cards and receive priority. Their intentions of registering to be an organ donor may be to receive priority if they ever need an organ transplant, but does that mean they should not be entitled to receive priority? If these individuals were not allowed to be registered donors, then they would not be eligible to receive priority simply because of a condition they have. 

Looking at the Organ Transplant Act as a whole, does giving priority to donors devalue the act of donating an organ because there is a reward? For as long as organ transplantation has been around, it has often been considered a selfless act (Levy). Israel’s law could influence people to register as organ donors, consent to a relative donating organs, or be a living donor in order to receive priority, rather than to help others. However, the other side of the argument is that no matter whether the intentions for organ donation have changed, the law has increased organ donation rates and therefore saved more lives. From this utilitarian perspective, the law would be ethical as it has increased the overall number of lives saved. 

The prioritarian model labels systems in favor of giving organs to those who are suffering the most. In medicine, this model says that resources and treatment will go to the sickest people first. Both the U.S. and Israel use this model by first assessing medical urgency for organ transplants, and prioritizing those individuals. A critique of this model is that it is difficult to know who the sickest people really are. This can be seen in organ allocation as it is difficult to measure which patient is the most medically urgent. In addition, the sickest patients may have lower chances of post transplant survival, therefore, not benefiting as much from the transplant. This could be a waste of resources if the patient did not survive the transplant.

In organ allocation, the egalitarian model gives priority to those who have been waiting the longest. For example, in the U.S., a factor that goes into determining who receives a kidney transplant is time waiting. More broadly in medicine, the foundation of the egalitarian model is the equality of every individual. Priority is often given to the people who are most burdened by their condition, however, this can also be difficult to measure.

The framework of utilitarianism is the greatest amount of benefit for the greatest number of individuals. The utilitarian model can be applied in organ allocation as aiming to save the most lives. The most just situation in this instance would be increasing the overall or total health of the population. The U.S. and Israel both attempt to save the most lives, and aim to balance justice when accomplishing this. As mentioned earlier, a utilitarian perspective would be that Israel’s law is ethical if it raises overall donation rates, and therefore saves the most lives.

The U.S.’s system gives everyone an equal evaluation of health status and uses this information to determine place on the waiting list. According to the Organ Procurement and Transplantation Network in the United States, “One well-known interpretation of the principle of justice holds that the just or fair arrangement is the one that identifies the worst off persons or groups and arranges social practices so as to benefit that group.” This reflects the system in the US where the highest priority goes to the sickest patients. However, evaluation can be manipulated. These inequalities can be seen in determining medical urgency and organ donation rates across different regions of the country. 

In the U.S., there are clear disparities based on geography. Across the country, there are varying rates of death that can lead to organ donation, such as strokes, opioid overdoses, and accidents (Penn Medicine). In regions with more causes of death like these, more organs will be available for donation. In addition, there are differences in access to healthcare and therefore access to being listed on the transplant waiting list. A study done showed that a moderately ill patient had a 60 percent chance of receiving a liver within 30 days, while a similar patient in Minnesota had a six percent chance and another patient in California had a one percent chance. Similarly, a transplant candidate would likely have to wait longer living in a heavily populated area such as New York City, compared to a more rural area with a smaller population. In 2018, the HHS significantly increased the distance that a deceased donor would have to be from a transplant candidate. The sickest candidate within this larger radius would be offered the transplant first. The HHS hoped this law would allow for transplant hospitals in major cities like New York, Chicago, and San Francisco, where the organ shortage was more severe, to procure organs from other parts of the country (Bernstein). Although the U.S. prioritizes the sickest patients in theory, these statistics show that there are clear issues with justice. It is unfair for a patient to have a lower chance at receiving an organ based on where they live. In fact, there are known cases where people have moved to regions where organ transplants are more available, which creates further issues with justice, as only certain people have the ability to do this.

In Israel, there are many varying views on whether the priority system is just and equitable. Israel’s system prioritizes reciprocity, as they give priority to those who have donated organs or intend to donate organs. Those who are willing to receive an organ should also be willing to donate one. Israel also gives priority only to living donors who donate to an unspecified patient. This is a big contrast from the U.S., where the only individuals prioritized in organ allocation are children and previous living kidney donors, mainly due to their increased risk for health complications. Directed living donors risk their lives to donate organs, and still decrease the organ transplant waiting list by one, therefore, increasing other individuals’ chances of receiving an organ. So, it could be argued that directed living donors are not receiving justice for their organ donations (Quigley).

Another group of people that are disadvantaged by the priority system is those who have religious objections to organ donation. This system is unjust for people whose religious beliefs prevent them from being an organ donor as they would automatically be unable to receive priority because of their religion. Many Israelis are also uneducated about the priority system or have low medical literacy, not understanding death declaration, organ procurement and transplantation. For example, the Haredi population stays away from television, magazines, newspapers, and radios, so they would likely be less educated on Israel’s priority system, and therefore at a disadvantage to receive priority. This group of people must be taken into consideration when evaluating Israel’s priority system.

Utility, or the most overall good, can be looked at through many different lenses. It can be prioritizing the sickest patients or the patients with a higher post transplant survival rate. It could also be prioritizing based on need or willingness to donate. The Organ Procurement and Transplantation Network in the US put out a statement regarding utility saying “If one considers the saving of a life to be a great medical good, then utility would account for priority for extremely urgent, life-saving cases. However, if the probability of saving a life was greater if the organ went to another patient whose case was not as urgent, then utility would favor giving the organ to the better off patient rather than the one near death.”

The system in the U.S. incorporates utility by allocating organs to patients within the boundaries of the local OPO, then in the region, and lastly, nationally. With this allocation system, it is less likely that organs will be wasted, as the closer the patient waiting for transplant is to the organ, the less likely it is that the organ will be outside of the range of time that it can be transplanted in. For example, hearts and lungs can only have four to six hours between the time of procurement and transplantation, and the U.S. ensures that these organs will not be wasted by not being donated within this time frame. 

Organs are also first allocated to the sickest patients, attempting to save the most number of lives. As mentioned before, there is room for manipulation in this policy because it is difficult to tell who the sickest patients really are. In reality, due to some hospitals overtreating or prioritizing those that may have an easier recovery, the sickest are not always the first to receive transplants. HHS officials say the U.S. “prioritizes equity over utility”. This shows why the U.S. would not adopt a policy of prioritization like the one Israel. In Israel, the main goal was to increase the number of donations and transplants, therefore, increasing utility. This law led to an increase in utility, but created more injustices within the system. According to the HHS statement that the U.S. prioritizes equity over utility, a fair system for all citizens would likely be kept in place instead of a system that would increase donation and transplant rates.

Israel, having very low organ donation rates, attempted to do “the greatest good for the greatest number of people” with its new prioritization system. In order to increase the number of deceased and living donors, the new system gives individuals that consent, register, or donate organs priority, an effort to increase the number of organs donated. Although consent rates went up and there was an increase in people who registered to be organ donors, the change has not drastically affected the number of organs that have been donated and transplanted, as organ donation rates still remain relatively low. In Israel, the priority system places an emphasis on utility, which must be weighed against the inequalities this system has created. However, the system has not significantly raised organ donation rates, but instead it has put many different groups of citizens, including those with religious objections to organ donation, at a disadvantage to receive an organ transplant.

Many aspects of the U.S. organ allocation system can be improved to make it more just and equitable. First, there should not be disparities of who is prioritized based on access to treatment or geographic location. Starting with access to treatment, it is unethical for hospitals to over treat patients in order for them to appear more medically urgent. This compromises a system of prioritizing the sickest patients. Similarly, transplant centers should not prioritize those who may have better post transplant outcomes so that they are scored higher. With integrity in these cases and hospitals following the prioritarian model, the sickest patients would benefit. In terms of geographic location, organ sharing networks in the U.S. have been working to fix this problem of inequity. This issue is deeply rooted in the organ allocation system, and will take time to fix. In the future, we will see if broader sharing borders and new policies increase the equity in the U.S.’s organ allocation system.

These policies demonstrate two different approaches to organ allocation, but which system provides the greatest benefit to the greatest number while being just and equitable? Moving onto Israel, the Organ Transplant Act has brought about many unintended consequences. Specifically looking at the prioritization of individuals whose first degree relative was a deceased organ donor and individuals whose first degree relatives hold a donor card, it is interesting that an individual would benefit from their relative’s actions. The justification for this is that it would help to raise overall donation rates by increasing family consent rates, but in this case, one person may have an advantage in receiving priority for transplant because of a relative’s decision. For example, if there were two possible candidates for transplant, a registered organ donor or an individual whose family member was a deceased donor, the ladder would receive priority because of their relative’s actions. In addition, an individual with more first-degree relatives would have a larger chance at receiving maximum priority, which makes the system unjust for those with fewer first-degree relatives. Israel also has a large religious population that is disadvantaged by The Organ Transplant Act. It is unjust that an individual would have a lower chance of receiving a transplant due to their religious beliefs.  Although this prioritization system may have increased consent rates, there are many inequalities that come with it.

Another interesting aspect of Israel’s law is that only living donors who donate to unspecified recipients receive priority. Living donors who donate to, for example, a relative, are still donating an organ, but would not receive priority points. Even if a living donor makes a donation to a relative, they are still making someone else’s chance of receiving an organ greater. They are decreasing the number of candidates on the organ transplant waiting list, even though they are not contributing to the public pool. In circumstances where living donors make a donation to a specified recipient, it does not follow the normal policies of organ allocation. If they are not contributing to the public pool, the organ will go to a specified recipient who is likely not the sickest patient on the transplant waiting list. However, the contribution of decreasing the total number of people on a transplant list and risking health for another individual should be enough to give any living donor some level of priority. 

These prioritization systems are in place to deal with the allocation of a scarce resource. The issue of prioritization for organ allocation stems from the organ shortage crisis. With more organs available, prioritizing one individual over another would not be necessary, so what is the best way to deal with the root of the issue: the organ shortage crisis? The top five countries with the highest organ donation rates, as of 2016, are Spain, Croatia, Portugal, Belgium, and France, all opt-out countries. On this same list, Israel is ranked 28th out of 38 countries (International Registry in Organ Donation and Transplantation). Therefore, Israel’s incentives for organ donation with its priority system have not sufficiently increased organ donation rates. More countries are beginning to switch to an opt-out system of organ donation. The United Kingdom switched to an opt-out policy in 2020, joining many other European countries. Many studies say that opt-out policies increase donation rates, but it is difficult to determine how this policy would affect each country.

 If Israel were to have an opt-out system, it is possible that they would have a large-scale opt-out, similar to what happened in Chile. Many people may opt-out due to religious objections to organ donation or misinformation about which religions object to organ donation. An opt-out system in Israel would spark further debate about justice and equity in relation to religion. In an opt-out system, people may be uneducated or undereducated about the policy and, therefore, not opt-out of organ donation. People’s preferences for being or not being a deceased donor may be compromised in a system with presumed consent. This issue would be increasingly complicated in Israel with religious objections and the lack of education about policies, such as organ donation. The priority system would also have to be changed. Instead of priority to registered donors, it would change to prioritization for people who have not opted-out, like in Chile.

So, how can it be determined whether the priority system in Israel is ethical or unethical? It comes to a balance between the principles of utility and justice. The law increases utility by raising overall donation rates and is just for those who are willing to donate, but it is unjust and inequitable for those with religious objections to organ donation, fewer first-degree relatives, and those with less knowledge of the priority system. In addition, although organ donation rates in Israel have slightly increased, there has not been a significant change in the number of transplants performed compared to the number of people waiting to receive an organ. As Israel continues with this priority system, we will begin to see the long-term impact of the Organ Transplant Act of 2008. In the coming years, we will see whether other countries follow in Israel’s footsteps or take other approaches to manage the organ shortage crisis. It is clear that the gap between the number of organs donated and needed is growing wider, and each country must determine not just who to prioritize for transplant, but also determine whether to prioritize a system emphasizing justice or utility. 

In final analysis, the Organ Transplant Act in Israel is not the most ethical system of organ allocation as in this case, the principle of justice outweighs utility. The law prohibits certain people from receiving priority based on their number of first-degree relatives, religious beliefs, and knowledge of the priority system. These inequities are not outweighed by the principle of utility as organ donation rates have not significantly increased. Although the intentions of the priority system were to raise the overall utility, it has had many unintended consequences, leaving injustices in Israel’s organ allocation system.