June 18, 2013


So many years on my part of not watching television (I don't own one), never listening to radio and newspapers frivolously scanned for headlines while waiting for coffee to-go and  the further censoring of information by directed and specific searches on the internet and yet the writing is clearly on the wall.

"Stick to individual things", was some good advice I was given lately. I  was told to compartmentalize in order to counteract that natural inclination of mine to make connections between disparate issues all the time.  A kind of anti-reductionism, if you will. But being an intuitive this makes perfect sense since intuition is about what is around the corner, out of sight, working on the puzzle with islands of pieces instead of dutifully building the linear edge first.

So now though, it is clear that the world is going to hell in a handbasket. The latest proof of this is the initiative of the newly placed health minister here in Israel who is pushing an agenda to make organ donation 'compulsory' after death, unless you opt out of it in advance. There is an added initiative to no longer require concurrence from family members which I completely agree with; once you have made your decision the family should respect that as long as death is determined in a manner acceptable to that family.
Apparently we are lagging behind other developed nations as to the percentage of families who do not concur to have their loved one's organs harvested.  Let me be clear, I am absolutely for organ donation (my daughter signed her card a few years ago) and would hope that if something were to happen to me I would be able to help others survive an otherwise lethal predicament. As the father of a catastrophically disabled child I hope, in the event that we once again encounter an acute decline, one that truly appears to me to be irreversible, that I will have time to make the decision to allow his organs to be used (the word harvested does not sit well with me in general, even with a para-medical background) for the benefit of another person, in a serious condition. 

I believe we should encourage people to donate their organs through education but not through draconian measures. There may be any number of reasons why a person has not filled in a donor card, or does not wish to. But here in Israel it is taken even a step further in that those individuals who have signed a card get preferential treatment through a 'point' system when the time comes to receive an organ, jumping the queue over those that did not sign. This is absolutely ridiculous, bordering on the criminal. The point system, briefly touched on here gives preferential treatment to those whose family members have either signed a donor card or previously donated an organ. Where exactly the medical precedence or priority fits in to this is not clear. Presumably some absolutely impartial doctors (have you seen any of those around lately?) would look at a case where two patients were in need of, say a liver, and be able to pronounce which of these two is more in need of said organ, judiciously allocating the liver to who needed it most. But what decides the degree of illness severity as being "needed most" is a very gray area. Presumably when there are two patients with conditions deemed nearly equally in need of that transplant, the preference is then decided for e.g., by how many years ago you signed your donor card.
With the impermeable tradition of many streams of Jewish religion being against organ donation, I don't see how they will possibly pass the new initiative into law, but then I am not aware of how the preferential treatment, a provision in the law which states that a medical institution has the prerogative to prioritize,  is implemented in reality.

The scenario of the authorized review board weighing two patient's condition in order to establish which is the more needy is a delicate situation where the decision is never clear cut (otherwise there would be no discussion). Now add to it the knowledge that one consideration in this discussion of who lives and who dies, is whether a person signed a donor card, or whether a family member signed a donor card. Will the beliefs of the individuals on the committee about card signees and non-donors sway their decision when weighing the often incomparable parameters of life threatening conditions?

To me all this is akin to a serious traffic accident where the emergency personnel arrive at the scene and see two cars involved. A very quick assessment must be made who to extricate and treat from the wreckage first, occupants of car A or car B. Car A has seriously injured passengers but so does B, as a matter of fact one must assume that the occupants of B are more injured in this two car accident since no one in car B was wearing a seatbelt. The seatbelt here is analogous with signing an organ donor card. So now the decision becomes quite easy for the paramedics (since both cars have 'seriously injured' occupants) and they will first help those who wore a seatbelt.
The idea that anything except acute medical need be the deciding factor seems rather slippery to say the least. Just as the case, not long ago in the news, of the disabled girl, cognitively impaired, who was deemed to have a lesser quality of life and thus (initially) refused even registration on the waiting list. Of all the places to introduce questionable elements into this life and death dilemma, favoritism, such as whether a family member previously donated an organ, is built into the "point" system helping decide whether you live or die. Such a system should necessarily include a few alternative, well thought out elements.

Here is also a typical case where the left hand does not know what the right hand is doing and yet one, does their work dependent upon (and safe within) the knowledge that the other knows what they are doing.
The declaration of death is for me a tricky subject, amongst other reasons having had my best friend declared brain dead  by several neurologists after a severe motorcycle accident; "his brain is mush", but the family not having any of it and persevering and while he is severely brain damaged he is also today, thirty years later, a husband, a father and a practicing dentist. Of course exceptions do not make the rule and his case is extraordinary, although to which degree we will never know since many people readily align themselves, in severely stressful situations, with the comforting prodding from doctors, nurses, social workers and family that there is no hope. For someone who says he does not believe in hope, I seem to be saying there is always hope. Not precisely since the fact of survival of individuals who were not expected to survive, speaks for itself, and I know of many such cases.
Relevant here is that in deciding whether to harvest organs we have to establish finally, that death has taken place. In the 2008 law of organ donation here in Israel the concept of death is based on the law of anatomy and pathology from 1953. I wonder if we have gained any knowledge on what constitutes physical death since then? My dear friend P. Dzialo comes to mind, with his son Adam who spent 25 minutes underwater, drowning in other words, and yet is alive today because there was a refusal to define death. While some individuals wish to define their death with the same criteria as the manner in which they lived their lives, i.e. cognizant and self reliant, the subtraction of those two elements resulting in a wish to die, which seems reasonable to me, a great deal of gray area lies with accident victims or catastrophically (though not necessarily terminally) ill and disabled children. If they do survive, will their quality of life be enough, many ask? You will find out the answer to that question if you give life a foothold, but if you do not, you will be left wondering the rest of your life. It goes without saying that the answer you will get can of course lead to a profound sense of regret at having waited for it.

We certainly need to learn more about this reality but meanwhile laws are written, stuck in a kind of catch-up to modern society where interpretation turns into "consensus opinion" and the information people are given is not actually informed  but consensus decision. The option of a small chance at survival is not given much time, like a minority report, a dissident voice that would merely clutter the clear, pristine and noble issue of death and organ donation.

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