Balancing age and organ transplantation waiting lists: An Israeli example
Following the acceptance of their commentary in the Age and Ageing Journal, Professor Israel Doron summarises the procedure undergone by him and his colleagues, to address the discriminatory practice of imposing age limits on organ transplantation waiting lists in Israel.
Across the globe, societies are struggling to shape their practices and policies regarding organ donation and transplantation. This dynamic reality is evolving as the world ages and ageism is being recognised and increasingly resisted. Nevertheless, when comparing laws and regulations in this field, one finds that despite the fact that many countries have abolished recipients’ chronological age as a formal limitation criterion for listing for transplantation, the recipients’ age is still very relevant.
Like other countries, Israel is struggling to shape its organ donation policies. The policies of the Israeli National Transplant Center have traditionally limited listing candidates for the various transplanted organs (except kidneys) by maximal age criteria, mainly due to shortage in donated organs. However, following public criticism of this seemingly discriminatory rationing, in 2013 the Ministry of Health appointed a committee to examine the use of chronological age criterion for inclusion in the organ transplantation waiting list and for organ allocation policy.
The committee comprised 25 members, including professionals, representatives of older persons' associations, and representatives of candidates for organ transplantation. In addition, the committee canvassed public opinion by public invitation to appear before it, and to submit views and policy positions.
The committee first requested its transplant experts to review clinical data based on impact of recipients’ age on outcome in the various transplanted organs. Although negative correlations between recipients’ chronological age and post-transplant patient survival are evident for all organ recipients, the transplant experts did not consider the magnitude of survival differences among the various age groups to justify exclusion from the candidates’ waiting lists.
Given this medical perspective, the committee addressed the ethical, social and legal issues stemming from the exclusion of older people from the list of transplant candidates. One of the key utilitarian arguments which was raised was based on the assumption that older people have completed a good portion of their life expectancy, and accordingly, one should prefer the young who have yet to enjoy this. However, the committee deemed this approach incompatible with the changes in the social and legal perception in Israel, and sought to establish a more egalitarian and just approach.
Once it was clear to the Committee that it should move beyond the narrow issues of age as an exclusionary rule, and into the issue of the use of recipients' age as an additional relevant criterion in shaping a fair and objective organ allocation policy, the opinions differed. The majority opinion in the committee was that recipients’ age by itself should not be considered during organ allocation. In this sense, chronological age, in and of itself, should not be a factor at all. The concerns pertained to the fear of assigning value to each year of life, and the subsequent decision that some people are "worth more" and some are "worth less". Assigning value to recipient and organ life expectancy is, according to the majority opinion, an unrealistic task that neutralises all those "life events" that unavoidably intervene in the course of life.
The minority position, on the other hand, argued that chronological age should be considered as a break-even allocation consideration. This position relied on two main reasons: one is the cycle of life – there is significance to the years a person has already lived and to those he is expected to live (even if this is only according to the statistical life expectancy); and the second is the significance of the number of years the donated organ, as a public resource, will serve its recipient.
The Israeli experience, as described above, exemplifies in our view, the complicated reality that many societies face today: a reality that combines population ageing with changes in norms and values. The Israeli committee recommended the abolition of chronological age as an excluding criterion for listing candidates for transplants. Also, by its majority’s position, the committee recommended ignoring recipients’ chronological age in organ allocation, as long as there is no medical cause for differentiation on the basis of age. The committee has recommended that each candidate for an organ transplant should be evaluated, amongst other criteria, for his or her frailty status and that this criterion should be incorporated into the decision-making process of listing candidates for transplantation.
These recommendations were approved and formally adopted by the Ministry of Health in Israel as of April 2014. Yet, it is for future studies to assess the impact of these recommendations on the reality and experience of organ transplantation in Israel.
E Katvan, I Doron T Ashkenazi, H Boas, M Carmiel-Haggai, M Dranitzki-Elhalel, B Shnoor, J Lavee
University of Haifa, Israel