Dr. Yonatan Halevy
TRANSCRIPTION OF VIDEO
Between 70 and 90 people in Israel die annually because of lack of organs, and most of these people could be with us today. You know, you have to deduct a few failures in surgery, but because the success rate of organ transplantation today runs between 80-90% – – depends on how soon you do it, it depends on the organ – – most of these 70-90 people every year could be with us today if availability of organs for donation was more prevalent in Israel / was higher in Israel today.
I served as the Chairman of the Israel Transplant Center for the last 4 ½ years. Before my time, shortly before I came on board, my predecessor tried to form some contact with Euro-Transplant which is equivalent to the American UNOS and to the Israeli Transplant Center. And I understand that such an agreement necessitated mutuality. And when they tried it, and we got our first organs — mainly kidneys because it’s less practical for hearts and livers because of the time allowed between harvesting the organ and transplanting it, which is up to 24 hours in kidneys and only around 5 hours for livers, hearts, and lungs. So I understand just from reading the history that few kidneys survived here, and we could not reciprocate because of the low availability of organs in Israel. So this agreement did not pick up. The Chairman of Euro-Transplant came here, we negotiated – – it was already in my time – – and it was very clear that we will not be able to reciprocate. It would be mainly a unilateral agreement which, of course, there is no reason in the world that the Europeans should agree to it.
Nearly 5 years as Chairman of the Israel Transplant Center, I am amazed to see – – and I think there is no other example in medicine to this – – that we lose lives, tens of lives every year, that could be with us if we would have more signatories on donor cards. And it’s an absolute moral obligation, and has to be a moral commitment of everyone in Israel and around the world (but I deal with Israel) to sign a donor card, because this is the only solution to minimize the number of unnecessary deaths.
Unfortunately, Israel is lagging behind most of the countries in the Western world in willingness to sign donor cards and in the prevalence of consent of families to donation of organs of their beloved ones when he died and pronounced brain dead.
Today in Israel, close to 1,000 patients are waiting for an organ. For kidneys, it’s around 600 patients. The number of cadaveric kidney transplants performed annually in Israel is barely comparable to the number of new patients who join the list annually.
There are about 120 patients waiting for livers, and we do around 50 livers a year. So again, this is barely comparable to the number of people who are joining the list waiting for liver transplants every year. In the case of the livers , the United States is in a worse situation than Israel but that has to do with alcoholic liver disease; it is much more prevalent there, and our burden of liver disease is mainly Hepatitis C. The same proportions exist for hearts, lungs. These are the four main organs; the pancreas is usually transplanted together with the kidney for the Hepatic patient.
So the situation in Israel in terms of awareness of the public and mainly willingness to recognize brain death as death in every respect exactly like cardiac death is, as I said, lagging behind.
We do not have evidence-based research to point to the key factors that make the Israeli population different than other Western culture populations. I think there are a combination of factors.
I think without scientific proof, it would be quite safe to say that the average Israeli – – maybe the average Jew, I don’t know about statistics regarding Jews from around the world – – but I think that the Jewish heritage is such that the average Israeli has more inhibitions than his counterpart in England, Norway, and France when it comes to death, to the concept of death. He prefers to get to the grave whole; he has a lot of misconceptions about what happens if he donates an organ; and he is not open to facts in this field like that these organs anyway disintegrate within a few months. Some people say three; some between three and six months, the liver, the kidney, the heart, the lungs are not in the grave anymore; it’s only the skeleton that remains, and the rest just disintegrates.
And it’s very difficult to convince Israelis in these realities. They raise reasons when they are asked, as “religion” which is one of the main reasons but not the only one: That not all Halachic authorities recognize brain death as death in every respect. They raise arguments like lack of confidence in the physicians. Namely, that if I sign a donor card, maybe the physician will round the corner and will be hasty in pronouncing me dead when I’m not dead yet. So I’m aware of the process of estrangement that takes place nowadays between patients and physician. It has to do with high-tech medicine, and with the fact that we spend less time with our patients. But to suspect the physician not to be accurate about assessing death I think is far too much. Not to mention the fact that brain death is assessed by a committee of two (2) physicians who have nothing to do, not with the treatment of the patients and not with the transplant patient process. These are independent neurologists and internists, or two (2) senior neurologists, who will come in and use a checklist of parameters that they have to use, and to sign each one of them that the patient abided by in physical examination and in technological assessment; and only then the patient is pronounced brain dead.
Some people mention ‘Eyan ha’ra” – – evil eye – – as a reason. You cannot argue with that logically. You can only say that by the same logic, maybe signing a donor card will be, you know, a guarantee for long life. I mean, the logical basis for this claim is definitely equal to the claim that my life will be shortened because I signed a donor card.
These are the kind of reasons that are raised, and I personally do not believe that these are the general reasons. I think that these are only excuses because of some mysterious apprehensions that probably exist among Jews at large and with Israelis in particular, more than among members of other nations.
We have on our list 250,000 signatories. So, the Israeli population is 6.7 million. If you deduct two million that are under 18, so you get to around 4% of the Israeli population. Why, we see countries where the rate runs from 10-25%.
Since the publication of the Harvard Criteria in the late 60’s, the medical community accepts brain death as death in every respect. You asked me right now if the medical community is unanimous.
I would say that physicians who have reservations are, first of all a very, very small, tiny minority. (B) The reservations stem from ignorance, usually. And anyone who learns the stages of assessing brain death today, and is familiar with the clinical material, will accept immediately. And, as I said, there is a small, tiny minority in our efforts – – when I say ‘our’, I mean the Israel Transplant Center’s efforts to educate physicians around the country as to the brain death – – sometimes we are overwhelmed by the amount of ignorance. And those who question the validity of brain death as death in every respect are usually ignorant, never touched the subject. Once they are educated, they unanimously accept it.
How confident we feel about our ability to assess unequivocally that brain death is there, today, the answer is 100%; more than ever in the past. If you consider that the medical community around the world accepts brain death as death for over 35 years now. The technology that is at our hand today to verify that it is brain death is so much better than we had in the past: By evoked potential, the famous Bera test, the transcranial doppler sensor that proves no blood supply, not to the brain and not to the brainstem. This is the ultimate proof. So if you combine clinical bedside criteria to criteria that have to do with the respirator – – you disconnect the patient from the respirator, the apnea test, and you add to this the ultratechnological assessment manifested by the visually evoked potential, measuring electrical activity in various regions of the brain after stimulation of these specific regions, and the proof that there is no blood supply to the brain and to the brainstem, I feel fully confident that our assessment is accurate, and I will have no hesitancy to pronounce a patient based on these assessments as brain dead and consider him dead as if his heart stopped pumping and stopped beating for a few minutes.
No one in history has woken from brain death the way we assess it, according to the rules that we have today to assess brain death. It would be in my eyes more plausible that someone who is pronounced as cardiac death, and that it was not assessed long enough, and this has been reported, that the heart will beat again if the resuscitation process was not long enough than after brain death.
Anyone who witnessed a patient who passed away from brain death will not even consider the possibility of coming back from this situation.
Coma is a prerequisite for brain death, but it is not enough. I mean, patients in coma wake up all the time. I mean, coma is a wider, where there are various degrees of damage to the brain, many of them reversible. I mean, if we take what we call persistent vegetative state today (PVS), this is very far from brain death. These are the stories that you read in the papers, that after 9 years, the patient woke up.
Most of these patients are not even on a respirator. In order to even consider brain death, you have to have a deep coma; the most basic reflexes are absent, like the corneal reflex, the reaction of the pupils to life which are very basic; you need the patients to be in extremely deep coma in order to have this; you have to have no spontaneous respiration; as I said, you disconnect the patient from the respirator, and for 5 minutes, you don’t see any spontaneous respiration; of course, a flat curve of the electrical activity of the brain (the electrocephologram); no response to any external stimuli – – to the IO region and the E region represented in the brain; and no blood supply to the brain.
So, coma is only one prerequisite. And most patients in coma are not brain dead. But all brain dead patients definitely have to be in deep coma.