Until medicine finds better answer, quest for organ donors must continue.
By JUDY SIEGEL-ITZKOVICHorgan donation transplant 224 88(photo credit: Courtesy of www.linksambulance.co.uk)
Tamar Ashkenazi yearns for the day when new medical discoveries will make her job obsolete. As head of the Israel Transplant organ donation coordination center, the registered nurse believes that eventually stem cell research, efficient and self-contained artificial organs or another breakthrough will make it unnecessary to "harvest" human hearts, kidneys, livers, lungs and other organs from live and dead donors for transplant to patients who need them.
But in the meantime, she works days and sometimes nights to ensure that organs that can save lives are reused rather than buried to decay.
Ashkenazi, a blonde, blue-eyed mother of two who was born on Kibbutz Hashita in the north, developed a love for helping people as a youngster. When other children were sent to harvest olives and other fruit, she volunteered in the kibbutz clinic instead. When in high school, she traveled to the development town of Beit Shean to work with welfare families.
"I had no training; it was all intuitive," Ashkenazi recalls.
At 18, she chose nursing studies over social work, graduated and worked in hospitals, after which she completed her MBA and a marketing course. This led to six years in charge of a pharmaceutical company's peritoneal home dialysis project in Ashdod. A friend who in 1997 showed her a want ad for coordinator of Israel Transplant - the country's new organ transplant transplant coordinating center - led to her current job.
"In those days, hospitals harvested organs and transplanted them into patients they knew needed them; there was no nationwide priority ranking." The State Comptroller wrote a critical report on the allocation of organs, leading then-Health Ministry director-general Prof. Gabi Barbash (now director-general of Tel Aviv Sourasky Medical Center) to decide that a nurse be appointed transplant coordinator in each of 18 general hospitals.
The ADI Association - named in memory of Ehud Ben-Dror, who died in 1978 for lack of a donor kidney - solicits and registers potential donors and currently has 462,000 people aged 17 and over on the list. His parents, Dvora and Shmuel Ben-Dror, founded the organization 30 days after his death and named the organization (www.agudatadi.org.il) in his memory.
In the US, Ashkenazi explains, organ transplants are coordinated by groups called "organ procurement organizations" (OPOs) that are not affiliated to hospitals. There is a law there that requires hospitals to inform the OPO whenever there is a case of lower-brain death. Then, the OPO comes to the hospital to speak to the family and "harvest" the organ if they agree. No one in the US registers with a centralized organization like ADI; they only sign a statement on their driver's license if they are willing to be potential organ donors. But not everyone has a driver's license, so the ADI system of registering donors is better, she says.
In Israel, each hospital has its own coordinator who speaks to the family. Whenever an Israeli hospital transplant coordinator learns of a brain-dead patient with a beating heart, he (or more commonly she) speaks gently to the family about donation and prepares the medical staff.
There are 560 Israelis (including about 30 children) waiting for a kidney, 70 for a lung, 120 for a heart, 125 for a liver and a handful for a pancreas. About 20 hearts, 50 livers, 35 lungs, 10 pancreases and 150 kidneys (50 from live donors) are transplanted each year, but there are between 145 to 170 brain-dead patients who are potential donors.
With new protocols and solutions, brain-dead patients can be kept alive for some time, so Ashkenazi prefers that their loved ones not be forced to decide immediately or in the middle of the night. Only tissues such as corneas, bones or skin can be removed after the heart stops beating; for medical reasons, most organs must be removed from a lower-brain-dead donor who still has a pulse.
Ashkenazi recognized the importance of delaying bad news after learning that in Ethiopian Jewish villages, if an elder dies his relatives are first sent to sleep and given food and time to relax before being informed.
"It is very sensitive and thoughtful. Villagers come to offer emotional support to the bereaved family when they are informed and ripe emotionally and mentally. We have no more transplant committees in the middle of the night. If the families are rested, it's unusual for them to change their minds or regret their decision later."
Ashkenazi wrote her MA thesis on what encourages and discourages organ donation, and the marketing implications of organ transplant solicitation. Ashkenazi said her two children, aged seven and 10, hear about organ donations all the time, and are not afraid to go to cemeteries. She sometimes attends memorial ceremonies of donors instead of funerals," she says.
About 45,000 of those on the ADI register are observant Jews with cards that stipulate a rabbi of their choice be consulted before any organs are harvested. This idea was initiated by Prof. Jonathan Halevy, the modern Orthodox director-general of Jerusalem's Shaare Zedek Medical Center who until a couple of years ago was chairman of Israel Transplant; he was succeeded at Israel Transplant by Prof. Gabriel Gurman, a retired anesthesiologist at Ben-Gurion University's Health Sciences Faculty and Soroka University Medical Center. Israel Transplant, under Ashkenazi, has trained a few dozen clergymen of several faiths to serve as consultants to religious families of various faiths.
Secular, traditional and modern Orthodox Jews are most likely to sign the card or donate their loved ones' organs, while haredi Jews and Druse most often refuse. Israeli Arabs constitute about a fifth of the population and 30 percent of organ donors. She notes that Muslim Israeli Arabs are much less likely than Jews to argue when doctors say their loved one has suffered lower-brain death. "They immediately accept it and prepare the grave," she notes.
Some people of both faiths refuse because they believe a body should be "whole" when buried, even though an organ can save a life. If the person has an ADI card, almost all families agree to carry out this living will. Ashkenazi is disappointed that few haredi families in Israel are willing to donate their loved one's organs because their rabbis insist it is forbidden to take organs from a brain-dead person; these rabbis insist that no organs be taken from a person whose heart has not stopped beating; but in this case, most organs - except for heart valves, bones, skin and corneas - cannot be used for transplant. However, when haredim need organs, some don't hesitate to undergo such surgery abroad - using organs taken from brain-dead donors.
At the height of the Second Intifada, when Palestinian terrorists blew themselves up on buses and killed over 1,000 Israelis, some Jews whose loved ones were brain dead said they would not donate their organs to Israeli Arabs. But Ashkenazi, who has a master's degree in business administration in addition to her BA in nursing, learned that her job as coordinator of Israel Transplant also required diplomacy.
"I described to the families the Arabs who needed the organs - that they were good citizens whose lives could be saved - and inevitably they agreed to donate them."
A law about to take effect will give priority for receipt of an organ to someone in a family who has signed an ADI card or donated an organ (although there will be a one-year waiting period to ensure that a person will not be immediately eligible after signing). Although there are numerous countries with "presumed consent" policies (that is, organs may be taken if the person didn't specifically forbid it when alive), this would never work in Israel, Ashkenazi concedes.
If an altruistic donor gives one of his kidneys, his medical and other expenses are covered, and he receives free life insurance and psychological help, but families unfortunately do not get income or property tax reductions or other financial benefits for donating organs, as such a proposal did not pass in the Knesset. "I have been struggling for permission to produce a 'VIP card' for families of donors who would get such benefits, but so far I have been unsuccessful," Ashkenazi shrugs.
As for "importing" kidneys from altruistic donors abroad, Ashkenazi says Israel Transplant does not encourage this, even though there are voluntary organizations in the US that promote this. "Bringing in kidney donors will discourage Israelis from giving organs because they will feel the system can manage without their contribution. And one has to be very careful that no money is passed to donors who claim to be altruistic. Israelis who want to donate a kidney to a relative or friend undergo a series of psychological and physical examinations to make sure they will not be harmed by giving an organ - although there is always some risk to the donor when giving a kidney, Ashkenazi notes.
Despite her hectic schedule - her cellphone rings five times during our two-and-a-half-hour interview - Ashkenazi voluntarily spends one evening a month holding a support group in Tel Aviv for donor families. She is also writing a book based on her experience, advising families who donated loved ones' organs on how to cope with their loss and memorialize them.
One day, she predicts, science will indeed find an alternative for organ transplants, but in the meantime, she is devoted to saving lives with donated organs.
This is an expanded version of an article written by the author for Bridges, the World Health Organization's English/Hebrew/Arabic-language magazine for Israelis and Palestinians on public health issues.
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