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Live Donation Of Organs Stirs a Debate Over Ethics

When David Koster wanted to help someone in need, he didn’t flinch from giving of himself — literally.

Koster, a 56-year-old Orthodox Jew from Brooklyn’s Borough Park neighborhood, donated one of his kidneys two years ago to a man from San Francisco, Calif., whom he met for the first time on the day of the operation. As soon as Koster saw an advertisement about the patient in a local Jewish newspaper, he was motivated to help — primarily because the recipient was Jewish.

“Your family comes first, don’t you think?” Koster asked rhetorically in an interview with the Forward. “People are interested in helping their own first, and then helping others.”

Koster’s decision — both to donate an organ to a person outside his circle of family and friends, and to seek out a Jewish stranger to help — places him at the center of a growing controversy over whether transplants from good Samaritans should be seen as a boon for the critically ill or a violation of medical ethics. The debate comes as the number of Americans on the national waiting list for organs has more than doubled during the past decade to 89,000, thanks in large part to medical advances.

Because the number of organs harvested from cadavers has not kept pace with the growing demand — in 2003, more than 7,000 people died while on the waiting list for organs — the number of organ donations from living people has risen dramatically in recent years.

More than three-quarters of the people on the national waiting list need kidneys, which can be donated safely from living individuals who are not close genetic relatives.

Some medical professionals are hailing increased donations from live donors, but others are concerned by a welter of associated ethical questions: Given America’s ban on the sale of human organs, how can medical professionals ensure that donors solicited through the Internet or advertisements are not being paid? Will the medically neediest patients be overlooked? And, if a donor is motivated to help individuals only in his or her own religious or ethnic group, are doctors who perform the transplants aiding discrimination?

For now, such questions are being answered on a case-by-case basis because patients who secure their own living donors are not dependent on the government-run system for allocating organs from cadavers.

The national registry is operated by a government-appointed non-profit called the United Network for Organ Sharing. The network distributes organs (almost all of which come from cadavers) according to medical need, rather than factors like the individual preferences of donor families. In 1994, after family members of a white supremacist murdered in Bradenton, Fla., were successful in insisting that the victim’s organ went to white recipients, the U.S. Office of Civil Rights ruled that the practice of allocating by race violated the Federal Civil Rights Act of 1964.

But at this point no similar federal restrictions apply to live donors, who are free to give their organs to whomever they choose, as long as a doctor agrees to perform the surgery. In recent years, several Web sites have been established that allow prospective donors to browse the personal profiles of needy patients, in much the same way that people now hunt for dates. One of the most popular of the sites,, has facilitated 11 transplants since its launch in February, 2004. While some transplant centers routinely accept donors who are found in this way, others do not.

Within the Jewish community, it has become increasingly common for patients to place advertisements for donors in Jewish publications, or for rabbis to make appeals on behalf of particular patients from the pulpit, even though organ donors — unlike marrow donors — do not need to be close genetic matches with their recipients. Dr. Stuart Greenstein, a transplant surgeon at Montefiore Medical Center in New York, said he performs, on average, 100 to 120 transplants each year, five to 10 of which involve Jews helping Jewish strangers.

Some observers say it is only natural that Jewish donors, such as Koster, who volunteer to help people outside of their own families, are particularly motivated to help other Jews.

“Organ donation is no different from any other kind of donation in respect to the order of priority of one’s beneficiaries,” wrote Rabbi Elliot Dorff in an e-mail to the Forward. Dorff, vice chairman of the Committee on Jewish Law and Standards — Conservative Judaism’s top lawmaking body — and co-chair of the bioethics department at the University of Judaism in Los Angeles, added, “Specifically, the Talmud asserts that one needs to preserve one’s own life first and then worry about one’s own family, then one’s own Jewish community, then the rest of the Jewish community, and then the rest of humanity. Given the way Jews were treated historically by non-Jews, it is remarkable that the Talmud requires us to give to the poor among non-Jews too ‘for the sake of peace,’ but one is supposed to worry about one’s family and community first.”

Robert Berman, the founder and director of the Halachic Organ Donor Society, an organization that recruits Orthodox rabbis to sanction organ donation, supports allowing directed donations based on ethnicity, because he believes that such a policy will increase the overall number of organ donations and ultimately benefit all transplant patients. His views will be published this August in an opinion piece in the Kennedy School Review, the journal of Harvard’s Kennedy School of Government, from which he received a master’s in public policy last month. His article also argues that the sale of organs should be legalized.

But Dr. Douglas Hanto, a professor of surgery at Harvard Medical School and the outgoing chair of the ethics committee for the American Society of Surgeons, told the Forward that he is more concerned with ensuring live donations are distributed equitably. “When someone says, ‘I’m only going to donate to a certain class of individual,’ to us that’s not fair, that’s discriminatory,” Hanto said. “We think it should go to the person who is the neediest on the waiting list.”

Nonetheless, even Hanto accepts some distinctions: He said he was not opposed to friends donating to friends, or even a member of a synagogue donating to another member, even though he is “opposed to someone in the Jewish community saying that I am only going to donate to another Jew.”

A similar view was expressed by Elaine Berg, the president and CEO of the New York Organ Donor Network, the nonprofit organization that coordinates organ and tissue donations in New York City and surrounding counties.

“You get to a question of where to draw the line,” Berg said. “If someone puts an advertisement in [a Jewish newspaper], then it gets a little more gray.”

The United Network for Organ Sharing has not explicitly opposed directing live donations to strangers, but its board passed several resolutions in June that are designed to discourage the practice. For example, the organization plans to develop a nationwide mechanism to allocate organ donations from living, anonymous donors. Berg, who was a member of the ad hoc committee that developed the policy, said the goal is to encourage live donors to donate anonymously to the network, rather than to specific individuals, so that priority is given to the people deemed to be the best candidates by medical experts.

But for all the wrangling among medical professionals, some patients contemplating spending years on the transplant waiting list seem disinclined to quibble over philosophical subtleties.

Alan Aronoff, 45, the owner of a background-check company who lives in Pomona, N.Y., suffers from hereditary polycystic kidney disease — which has also stricken his father, aunt and brother. He said the only way to cope with his predicament is to be proactive.

“I’m not going to just do nothing but sit and wait on the list till I’m called,” he said. “Maybe I have my own business because I go and create things and I build things. So it’s the same thing: If I need a kidney I have to go try to find one.”

Aronoff signed up with earlier this spring, and was contacted by a dozen people who were willing to help. But a childhood friend also stepped forward, and after compatibility tests came back positive, surgery was scheduled for September 20.

For now, at least, Aronoff counts himself among the lucky ones. “There’s way too many people who need kidneys,” he said, “The list is way too long.”

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