We kidney donors must make this difficult commitment on our own terms

It seems like another lifetime, but it was only four months ago that we came together on Israel’s Independence Day to celebrate our shared achievements as a nation. One of the accomplishments honored this year with the Israel Prize was the work of Rachel Heber and her late husband, Rabbi Yeshayahu Heber, who co-founded Matnat Chaim, an organization that works in tandem with the Health Ministry to encourage and facilitate altruistic kidney donation (i.e., from a living donor to a non-family member). Their efforts had a significant role in making Israel the world leader per capita in live kidney donations for 2022.

Last month, a more controversial element of Matnat Chaim’s work was in the headlines. Right-wing journalist Arnon Segal became an altruistic kidney donor through Matnat Chaim, and in a subsequent interview stated that he stipulated that his kidney be given specifically to a Jewish recipient. When a live donor is matched directly through the National Transplant Registry, they may not make any such stipulations. (The same is true for organs donated from a deceased family member.) But because Matnat Chaim is an independent organization, it is able to let live donors express their preferences as to the profile of the recipient and facilitate an appropriate match. (A statement defending this policy can be found on their website.)

In truth, this practice is less consequential than it may seem: there are so many people in dire need of kidney donations that a match who meets the donor’s criteria is rarely far from the top of the list. Moreover, it is a truism that every donation shortens the wait for everyone else. Nonetheless, Segal’s comment generated the predictable media fracas. Zehava Galon tweeted: “Even two kidneys are not enough to cleanse him of the poison that flows through his body, so what does it matter.” (She later apologized for her tone.) Segal shot back: “Let’s agree that everyone should donate their kidney to whomever they choose.”

Putting aside my feelings about Segal’s politics in general, as a fellow recent kidney donor, I found myself sympathizing with his position on this issue. To be clear, Segal stated explicitly that he was not advising other donors what to do, nor advocating any separation or discrimination within the Israeli medical system; this was simply his personal decision. This is the point I find salient: there is something deeply personal about donating a part of one’s body that should at least temper any arguments about what sort of rights the donor deserves to have or what sort of policies should govern the matching process. There is a place for discussion of rights and policies; there is also ample room to respect the organ donor’s perspective, even if one disagrees with it.

For example: “How would you feel if the kidney you donate is rejected by the recipient’s body?” (Approximately 5% of kidney transplants fail due to rejection or other complications.) Or: “How would you feel if, in a year’s time, you see your recipient on a street corner smoking a cigarette?” These are only some of the unsettling questions posed by the social workers and psychologists who interviewed me during the screening process. The best answer I could come up with is that if no one were willing to take these risks, the system would collapse. But overall, these questions left me profoundly helpless: I was embarking on an intensive, demanding process whose outcome was largely out of my control.

In order to cope with this lack of control, I chose to embrace it. I was already depending on the surgical team to maximize the chance of a successful transplant. I decided also to put my faith in the Israeli medical system to find the recipient who would make the best use of my donation; I would think of my role as almost entirely passive. In one interview, I found myself saying: “Once the kidney leaves my body, I feel that it’s no longer really mine.” I know that may sound like an extreme way to put it (a member of the National Transplant Board actually told me so), and, like Segal, I am not advocating that anyone else relate to kidney donation the way I chose to. This was simply the only way I felt able to shield myself from the possible emotional fallout.

Throughout the screening process, I felt the need to reframe my decision again and again to cope with different elements of uncertainty. Another such moment came toward the end of the process, when a member of the Transplant Board grilled me about the health risks involved and the lifestyle changes I would need to make. These included the small but not entirely negligible risk posed by invasive surgery under full anesthesia. Was this a risk I wanted to expose myself to? While my family was entirely supportive of my proceeding, others suggested that this was an irresponsible choice for me to make, as a husband and father.

Here, again, I felt that my subjective perspective on the process was essential to my ability to proceed. My journey to kidney donation began with my work as a teacher of Talmud and Halakhah (Jewish law), including topics in Jewish medical ethics. It was my research into the halakhic perspective on organ donation that first sowed the seed of my desire to become a donor. While there are a number of halakhic issues relevant to live organ donation in general, the fact that kidney donation is a life-saving procedure means that the only substantive concern is a cost-benefit analysis: Is one halakhically obligated to put one’s own life at risk in attempting to save another’s?

The Talmud (Sanhedrin 73a) implies that a certain amount of risk is considered acceptable: “From where [do we learn] that if one sees someone drowning in a river or being mauled by an animal or being attacked by robbers that one is obligated to save them? It is taught: ‘You shall not stand by your fellow’s blood’ [Lev. 19:16].” Similarly, R. Yosef Karo (1488-1575) cites the position that one is obligated to save another’s life even if it means putting oneself in a potentially dangerous situation, and he explains, “It seems that this is because [the other’s] life is definitely [in danger] while his life is [only] possibly in danger” (Beit Yosef, Yoreh De’ah, 426)^.

The countervailing position is expressed most forcefully by R. Karo’s contemporary, R. David b. Zimra (Radbaz; 1479-1573). In a strangely prescient responsum (Teshuvot ha-Radbaz 3:627), Radbaz addresses the very issue at stake in modern organ donation: Must one sacrifice a part of one’s body in order to save another’s life? (He considers a hypothetical scenario in which a despot gives someone an ultimatum to amputate a non-life-dependent limb, such as a hand or foot, or else he will kill someone else.) Radbaz rules that there is no obligation to sacrifice one’s limb, and refers to one who does so as a “pious fool.” His main argument is that the mitzvah of “You shall not stand by your fellow’s blood” is no weightier than other standard biblical commandments (i.e., those for which one is not required to lay down one’s life). Just as one is exempt from keeping Shabbat or fasting on Yom Kippur in a potentially life-threatening situation, so, too, one is exempt from the obligation to save another’s life if it involves a risk to one’s own life, e.g., as the result of blood loss when amputating a limb.

When modern medicine finally made organ transplants a reality, halakhic authorities were initially divided. One of the earliest authorities to support kidney donation was Rabbi Moshe Feinstein, who also went the furthest in challenging Radbaz’s reasoning. In a 1968 responsum, Rabbi Feinstein concedes to Radvaz that there is no obligation to put oneself at risk in order to save a life (Iggerot Moshe, Yoreh De’ah 2:174 §4). But he builds a compelling argument that the mitzvah of saving another’s life is weightier than other standard biblical commandments. Whereas one is not even permitted to endanger oneself to keep Shabbat or fast on Yom Kippur, one is allowed to put one’s life at risk in order to save another’s. His logic is fundamentally the same as Rabbi Karo’s: the certain loss of another’s life outweighs the possibility that the savior will die.

Previously, I had always related to Rabbi Feinstein’s responsum as a technical legal text. But as I grappled with the potential risks of the surgery, his words spoke to me in a new, more personal way. No one could tell me that this was something I had to do, but Rabbi Feinstein’s analysis convinced me that this was a risk I actively wanted to take.

It now strikes me that Rabbi Feinstein’s responsum can be read as having a broader societal message as well: the opportunity to save a life justifies taking risks, not only to one’s life but also to one’s ideals. Critics of Matnat Chaim’s policy often invoke a slippery-slope argument: “How can we allow any donor to discriminate against some recipients? What would happen if all kidney donors specified that they would donate only to Jews?” Yes, that sort of systemic discrimination would be horrific, but it is no more than a hypothetical possibility; it has not materialized in the almost 15 years of Matnat Chaim’s work. On the flip side, it is certain that turning away donors like Segal would mean that more patients will die while waiting for life-saving transplants, a terrible price to pay for ideological purity. This was almost my recipient’s nightmare scenario: I was matched with him only when a previous donor pulled out at the eleventh hour.

I have no idea what caused that potential donor to back out, and neither I nor my recipient presume to judge them. But I am grateful that the Israeli medical system was just as nonjudgmental of me, Segal, and the other 1,500 individuals who have donated through Matnat Chaim, providing enough leeway for each of us to make this difficult commitment on our own terms. It would be prudent for the rest of Israeli society to put aside its ideological differences and offer organ donors that same level of unconditional support.