 Thank you very much for coming to today's program on ethical issues and organ transplantation. We're delighted to welcome Professor Daniel Sperling to the University of Chicago. Professor Sperling is a senior lecturer at the Federman School of Public Policy and Government, and at the Braun School of Public Health and Community Medicine at the Hebrew University in Jerusalem. He teaches courses there on bioethics, public health law, and on health policy. He holds degrees from Hebrew University as well as from the University of Toronto. This year, Professor Sperling is a visiting fellow at the Petrie-Flum Center for Health Law, Biotechnology and Bioethics at the Harvard Law School. Professor Sperling has established the Jerusalem Forum for Bioethics, which is a sort of country-wide forum in bioethics to organize conferences, seminars, and they're looking forward to putting together graduate programs. Some of his past work has included books on posthumous interests from a legal and ethical perspective, the management of post-mortem pregnancies, and is also written on reproductive technologies, transplantation, justice in the health system, and other areas. Currently, his current book project is working on informed consent in an era of accountable care organizations and managed care, and that's the issue that he'll be studying this year at Harvard. So it's a great privilege to welcome him to our 7R series. His topic today is organ transplantation and organ donation in Israel, recent ethical and policy changes. Professor Sperling, welcome. Thank you very much for Professor Sigler and Professor Carling for this invitation. I'm delighted to be here in Chicago. Okay, so although transplantation surgeries are relatively successful processes and donation of organs saves lives and improves the quality of life of many people, only few are willing to donate organs for transplantation. While in many developed countries the number of willing donors has not rising significantly over the years, the numbers of people waiting for such surgeries has significantly decreased, increased, excuse me. The discrepancy between demand and supply of transplantable organs and the health and other consequences deriving from it cause a serious health policy problem that policymakers, ethicists, scholars, physicians, and others are trying to resolve for more than two decades. No wonder then that the legal framework related to the ethical, organizational, and technical aspects in the field of organ donation, most notably with regard to protecting the donor, establishing consent for donation, and determining brain death very significantly within countries. One of the major reasons for unsuccessfully resolving this problem lies in the fact that not enough serious research has been done to indicate what exactly are the causes and factors inhibiting and encouraging motivation for organ donation. Other than analyzing individual characteristics that may play a role in determining the likelihood of donations such as age, gender, education level, income level, et cetera, of course religious associations, the literature does not offer a complete response to whether ethical, religious, or social considerations prevent the public from donating organs, nor is it decisive as to whether it is lack of financial, emotional, or other incentives to donate that serve major obstacles. Other questions remain open. Should refusal to donate organs be explained by failure to convey the importance of donation or is it just the result of a specific and contingent legal mechanisms to allow for the extraction of organs from the dead concerning, for example, the requirement of consent for donation or statutory mechanisms to sufficiently acknowledge the concept of brain death. The legal and ethical debates on organ donation are usually not concerned with the reasons for our willingness or unwillingness to donate organs. Instead, these debates focus on two major concerns. The first emphasizes the benefits of donation, especially to the recipient, and seeks to encourage the feeling of solidarity and altruism amongst people in the society and to increase people's volunteer identity. The other area of concern involves the creation of some incentive, usually financial, but also in the form of granting priority for medical service such as transplant, thereby increasing the motivation to donate organs for transportation. However, both of these areas of concerns are limited in their effect. Empirical studies show that motivation to donate organs is influenced more by the negative attitudes of people who oppose donation than by the positive beliefs that donors have with regard to donation. Studies also show that increased education is consisting of public advertisements to increase organ donation awareness among the general population, training doctors and hospital teams to improve the identification of potential donors, and the way donation requests are presented to surviving families is ineffective and unlikely to have any significant impact on cadaveric organ supply curves. It follows from these studies that the contribution of imposing values such as altruism or solidarity on the motivation to donate organs is relatively insignificant and that a better way to deal with refusal to donate is to refute myths and false beliefs concerning donation and the circumstances surrounding it. The debate relating to financial incentives to donors or their family members is also limited in its effect. Such a debate raises serious moral objection and evokes weighty sentimental responses such as is one really free to sell his or her liver or heart, is payment not an undue or unjust inducement, are potential vendors of organs truly autonomous, do financial incentives not lead to exploitation of the poor who will sell their organs in order to survive, do they not express disrespect for the dignity and humanity of humanity and the treatment of others merely as means, with these incentives not resolved in broadening the social gaps in society and increase in justice and inequality and access to health. In addition, the existence of a commercial market for organs is usually located within a human trafficking framework. Advocating for financial incentives to donors may not be practical within these systems that prohibit commerce in organs. Finally, there is much evidence showing that existing markets in nations such as India have failed and did not result in increased successful transplant as a result of poor organ conditions. To the contrary, studies show that participants in organ sales report deterioration in their health status after, for example, nephroctomy. Moreover, assessment of attitudes of family members who had been asked for consent to donate organs of their relatives shows that financial incentives are less likely to make a difference in the donation decision than donor authorization. Recently, it was argued that our understanding of the motives for and motivation to donate or refuse donate organs should be a precondition to any public debate on organ donation. Drawing on the social science literature, it was suggested to look into the new factors that have not been sufficiently discussed in the literature and may affect motivation or lack of motivation to donate organs. One such area of concern relates to the symbolic meaning of the act of donation, the specific organ to be donated and the relationship between the donor and the recipient. Recent empirical work carried out in four European countries provides substantial support for such a suggestion. Moreover, other work recently done on unwillingness to donate specific organs offers new research directions to examine the relation between attachment to different organs in one's willingness or unwillingness to donate them. Following these new theoretical understanding and empirical findings, we decided to examine them more carefully in the Israeli context. So like in most of other Western countries with an opt-in organ donation policy, Israeli faces the same organ shortage problem also resulting in relatively low rates of consent for donation. So as of 2013, about 10% of the adult Israeli population has signed an organ donation card. This has dropped from last year which was 14%. While among half of the families whose relatives signed such a card, donation is refused upon death and this is one of the major problems. So you can see that all the number of people who signed donor cards has increased in recent years. Still the number of donations is relatively fixed and stable and as I said, the red symbolizes acceptance of donation whereas the blue is the number of refuses. So you see still that there are more incidents of refusal to donate among those that signed an organ donation card than those that accept. And you can also see that the number of transplant surgeries is relatively stable as well. There was a sharp decrease last year and this is due to an unexpected and an interesting decrease in the number of brain deaths in Israel that occurred last year. This was a decrease of 16% of the incidents of brain death and this has been investigated at the moment possibly due to a decrease in the number of car accidents that we've had recent years. Maybe I'll wait for questions in the end of the session. Is that okay? Is it okay for the decision of the person who's dying to have this organ donation card? No, it does support. But they can veto this previous. So as of January 2003, a little more than 1,000 people were waiting for transplantable organs and the list of these people is gradually increasing every year from 2006 until 2013. The number of people waiting for organs increased by 45% from 768 to 1,000 and more than 1,000. On average, it takes 2.7 years and 4.3 years to receive a transplantable liver and kidney respectively and along with these increase in the number of people waiting for transplantable organs, as I mentioned before, the number of transplant surgeries decreased. Okay, so what is the public policy surrounding this area? So public policy aimed at increasing donation rate includes promotion of living donations through special committees that evaluate and approve requests for such donations. According to a new law, living donors are paid by the government for 60 months of private or complementary health insurance, 60 months of incapacity to work or loss of income insurance, 60 months of life insurance, five consultation meetings with a therapist and seven nights of recovery in a hotel and a fixed sum of about $650 for travel expenses. So this is a very nice package of financial incentives and I will refer to it later on. It's all of those. It's all of those. Yeah, it's all of those. Consequential. Okay, now relatives of a deceased who donated organs are paid for funeral expenses and receive free entries to national parks and museums, although we don't have such many as you have. But still, it can be attractive to some. In addition, all sickness funds reimburse funding of transplantation surgeries outside Israel if evidence for organ trade is not found, of course. And brain death is legally acknowledged despite some religious opposition and I will refer to this later on. More interestingly, Israel has established a unique program in which prioritization of organ allocation is based on whether the recipient or her next of kin signed an organ donation card prior to the transplant surgery. Except for children below 18 or other patients who need life-saving transplantation, the program gives priority to a patient whose parents' siblings, children or spouse, signed an organ donation card and or donated life-saving organs as well as to a patient who donated a kidney, liver, lung lobes or that his parents' siblings or children or spouse donated these organs. Three levels of priority exist. First class priority without a waiting period for those who they or their close relatives donated while alive. A second class of priority for those who signed a donor card and a third class priority for those who they themselves have not signed a donor card but one of their relatives did. And since the program started in 2011 about 52 people already had transplantation surgeries under the program. So it's relatively new program. We still don't have much data on this. This is the only data that we have. Okay, so in this presentation I will introduce a recent study aimed at pointing to some original empirical data on the complex meanings and motivations that organ donation raises and the symbolic meaning of donation. The study is based on a detailed anonymous questionnaire serving public views on the subject. The questionnaire was distributed among random and selected part of the Israeli society including organ recipients, organ donors, soldiers, university and high school students and the general population. It inquires about respondents' personal and professional characteristics, their general intention to donate organs and their motivation and readiness to donate specific organs, their attitudes on organ donation, compensation to donors, state responsibility in the area of organ donation and other policy and ethical issues relating to organ donations. It also queries as to their knowledge of public policy and legislation affecting organ donation and transplantation and their views on the connectedness between the body, body parts and their sense of self. So a total of almost 1,000 questionnaires from various parts of the country were received, about 800 of which were found appropriate for analysis. 42% of respondents were main, most of respondents were born in Israel and raised in families with an Israeli or Eastern European origin. Respondents were ranging, the respondents age were ranging from 15 to 77, the means was 25, relatively young, most of them single. Respondents declared there were, about 85 of them declared they were Jewish, about 10% Muslims. When asked about their nationality, about 90% reported they were Israeli Jews and about 10% Arabs. In terms of their religiosity, 52% declared they were secular, traditional, 14 religious and one ultra-orthodox. The questionnaire were collected from various geographical areas. In our sample, respondents lived mostly in big or small cities, 75 of them had up to 12 years of education, 12% of them had more than 15 years of education and about 47 of them were at the time of the research high school students. And were soldiers, 27% university students, about 10% employers, et cetera. In terms of their income, about 62% had monthly income of less than 4,000 new Israeli shekels. You should understand that the average income in Israel is about 1,800 new Israeli shekels, so it's about quarter from that. And in terms of their health, most of them, about 90% of them reported they were generally healthy. Some had preliminary heart or heart disease, chronic or other diseases. In addition to the basic universal coverage that every citizen in Israel enjoys, about 42% of them had complementary health insurance and more, an additional of about 14% had private health insurance, so three layers of health insurance. Although our sample is not fully representative, the major characteristics of respondents generally correlate to the population, to the Israeli population. So we divide our findings into the following themes. So about 25 of respondents reported that they had signed an organ donor cart. More over 10% of the participants in the survey had donated an organ to a relative or had organ donation in their family. 6.5% of them received an organ for donation from their relatives. Of those who have not signed an organ donor cart, about 60% declared they were considering or willing to sign such a cart, and 39% reported they would not sign such a cart. Of the many factors that encourage organ donation, the following factors receive the highest rankings from one to five, where one represents no influence whatsoever, and five represents substantial influence. So donor's state of health receives the highest effect following by awareness of the deficit of transplantable organ's awareness that donation is crucial for saving a life, recipient's state of health, precedence for the donor's family in obtaining donated organs, and donor's family proximity to the recipients. Among the many factors inhibiting organ donation, the following factors lack of information on donation procedure, type of organ, the position or attitude of relatives, inflicting pain and suffering on the deceased, and the perception or concept of bodily integrity received the highest rankings. In general, people who are willing to donate organs to their relatives only while alive are likely to donate to any person, including for free after death. On the other hand, people who, while alive, are willing to donate organs to a relative and to a stranger for some compensation have a more affirmed opinion as to donations after death and are more likely to donate their organs for compensation to strangers than respondents in the first group. The difference between those two groups of respondents was found to be statistically significant. The type of residence, country of birth, income level, and health status of respondents did not have statistically significant effects on motivation to donate. Willingness to donate was found to correlate to age, education, gender, and religiosity. The average age of people willing to donate organs was 28, and of those unwilling to donate was 21. The difference between those two was found statistically significant. Overall, people who were willing to donate organs were more educated than those opposing donations. This is not surprising. Education, however, had more impact on after death donations than on living donations. People who, in addition to the national health insurance, had private insurance, whether complementary health insurance or private insurance, tended to donate more than those who did not. In our study, women are more likely to donate than men, while a statistically significant difference between men and women was not observed with regard to living donations. Women were more likely to donate organs to relatives and to a stranger for free than men and were less willing to donate than men to a stranger for some compensation after death. Generally, the less respondents declared they were religious, the more they were willing to donate organs. However, within respondents who stated they would not be willing to donate organs, there was no large difference between secular and traditional respondents. This finding may reflect a problematic nature of self-reporting of religiosity level, especially in the Israeli society, whereas one can argue the cultural influence of religion on secular practices such as practicing at the Passover Seder, management of corpses, performing religious marriages, etc., is very dominant. In our survey, the statistically significant difference between religious and non-religious or less religious respondents is observed with regard to donations after death. While in general, the first are more likely to donate organs after death than the latter, our study found that only with regard to donations to relatives do traditional respondents tend to donate more after death than secular respondents. In general, Israeli Jews were more likely to donate organs than Israeli Arabs. While no significant difference between Jews and Arabs was found in relation to living donations, the statistically significant difference was found between nationality and motivation to donate with regard to donations after death. Our survey examined the question of whether organs donors should be compensated for their donation, and if so, what is the type and the extent of compensation. While most of respondents agreed that donors should not be compensated or have not decided on this question, about 32 of them thought they should receive some compensation. Our study revealed that women believe much more than men that compensation should not be offered to donors. Around 65% of respondents would be prepared to pay any sum of an organ vital to save their lives. While some of the respondents were prepared to accept an organ at a reduced cost from an unknown source overseas, a large majority of respondents were not. In terms of its general contribution to organ donation, compensation was not found to be among the five factors most influencing willingness or unwillingness to donate organs. While alive, only 4.5% of participants are willing to donate organs to a stranger for monetary compensation, and only 7.6% of them are willing to donate with regard to a stranger after death. These are relatively little numbers. The vast majority of respondents are willing to donate organs for relatives only and without compensation while alive, and for every person, whether a relative or a stranger, freely after death. When asked about the type of compensation that participants would like to receive for donating organs, precedence in case that they or a family member should require a transplant is what most respondents prefer, and this was before the initiation of this new policy that I introduced. And this was significantly followed by money and reimbursement for expenses associated with donation. Precedence in organ transportation was suggested more by more mature respondents and by more educated respondents than money. The vast majority of those who prefer money for donations have not signed an organ donation card. Okay, so now I move to the newer results of these research. So one of the major contributions of our study concerns the exploration of interesting associations between a person's sense of self and the symbolic meaning attached to a specific organ and the motivation to donate organs. So we ask respondents to rate their willingness to donate to various groups of recipients who were divided by their proximity to the donor. On a scale from 1 to 10 where 1 stands for I would not be willing to donate this organ at all and 10 I would be highly willing to donate this organ. We received the following results, as you can see from the table, with regard to all organs' motivation to donate increases sometimes dramatically as you move to the right. So this is more approximate donation to a relative friend so this motivation with regard to almost all organs increases as the recipient is more approximate to the donor. When asked to rate various items including organs in terms of their closeness or link to the way respondents feel about themselves or see themselves, that is what I call the sense of self on the scale from 1 to 5 where 1 stands for very remote from what I am and 5 from very closely linked to what I am and when compared to the general motivation to donate organs to recipients in all categories of proximity to the donor from 1 to 10 where 1 stands for I would not be willing to donate this organ at all and 10 for I would be highly willing to donate this organ respondents reported the following results. So in our study the closest organ to 1 sense of self that is the way we perceive ourselves or see ourselves are brain, facial cells, heart, genitals, vocal cords and skin cells. These organs are followed by lung, hair, cornea, bone marrow, blood, nose, kidney, liver and pancreas. When the closeness of organs to 1 sense of self is controlled and respondents are divided and those who regard the organs listed in the questionnaire as remote as opposed to close to their sense of self we found a statistically significant relation between their closeness to the donor's sense of self and their general willingness to donate to all recipients regardless of their proximity to the recipient. So, but we found this with regard to this is the table that actually explores the general connection between the scoring for respondents rankings of closeness of sense of self and their willingness to donate the aforementioned organs and we find a statistically significant relationship between these two with regards to the following organs the genitals, vocal cords, heart, lung, liver, cornea and skin cells. So it follows that in general organs that are closest to 1 sense of self i.e. genitals and skin cells produce the strongest relationship. In our study we also examined whether there is a difference in respondents willingness to donate organs by their proximity to the recipient depending on the contribution of specific organs to 1 sense of self. When respondents are divided to those who regard the organs listed in the questionnaire remote as opposed to those to close to their sense of self we found that there are statistically significant relationship between the closeness of organs to 1 sense of self and their willingness to donate but that these relations apply to different recipients depending on the organ to be donated. So here you can find statistically significant relations with regard to the following organs but this starts only from a specific proximity to the recipient, yes. Just a clarifying question. By genitals do you mean sperm and eggs or do you mean ovary? Ovary, yeah. So it's like an hypothetical situation in which you could donate these, of course. Yeah. So you can see that it varies from which point the statistically significant relation exists with regards to, correlates to the proximity to the donor. Excuse me. And this is also reflected in the following table. So remoteness from the donor was also found to be impacted by the weight one attaches to the type of organ in encouraging or inhibiting motivation to donate. Hence the more respondents regard the type of organ as significant to their willingness to donate organs either as encouraging or inhibiting donation the more it will affect their likelihood to donate organs to a stranger and in most cases this will be a negative effect. With regard to donation to recipients who are close to the donor the importance that the donor attaches to the type of organ either as encouraging or inhibiting donation does not play a significant role as to their motivation to donate. The questioner examined participants' familiarity with three major policy frameworks affecting organ donation in Israel. That is Israel's Organ Transplantation Act. Israel's Brain Respiratory Death Act and the position of the Chief Rebonate on organ donation after death published in 1986. Our survey revealed that between 57 and 69% of respondents are not familiar with any of these policy documents and that the largest proportion of respondents familiar with them relates to the rabbinical position while a less significant number of people are familiar with both pieces of legislation. Secular respondents were more familiar with the Brain Respiratory Death Act than traditional or religious respondents maybe paradoxically because this act is aimed more at religious parties than at secular parties. For those who are familiar with any of the policy documents these documents made no difference in their willingness to donate organs in many of the respondents. Among the three policy documents the Organ Transplantation Act recreated the largest effect on willingness to donate organs and the rabbinical position had the largest effect on unwillingness to donate organs. So in conclusion, surveys made in Israel prior to our study indicated that more than 50% of the public is willing to donate organs in exchange for prioritization in organ allocation a much greater proportion than those choosing indirect financial compensation. Although ethically disputable the new national initiative for prioritization of organ allocation may receive further support from our study. However the very low impact of monetary compensation on motivation to donate organ demonstrated in the study should call into question the other legal and policy channels seeking to increase motivation through payment to donors although in the guise of reimbursement of expenses. I say in the guise because it's a fixed sum of none. You don't have to submit receipts it's just you are paid a fixed amount. Previous studies suggest that institutional framework and more specifically governmental settings and regulations in the form of legislation affect people's attitudes regarding a donation by reshaping the culture in which they live. However these studies were challenged by more recent articles also referring to an inverse association between the depth of information or knowledge about medical practices and processes involving organ donation and the attitudes and willingness to donate. As a Dutch scholar argued by enforcing legislation to maximize organ donation and transportation activities for special interest groups organ donation ideology reforms socio-political concepts. Such legislation may come at the cost of limiting people's liberties and undermining established cultural and religious views. More generally as in the Netherlands a study indicates that the impact of legislation on the increase of donor organ supply can be very limited. Most of the public is unaware of legislation or is skeptical about its weight in shaping deeply rooted values that play a role in constituting one's motivation to donate or not donate organs to others. Our findings suggest shifting our attention from the impact of social feeling including through social interactions on motivations to donate organs to a more self-centered approach stemming from a donor's perception of either or herself and the symbolic meaning one attaches to the act of donation and to the organ at stake. While previous studies concerning willingness and unwillingness to donate specific organs focused on an associated donation with disfigurement of the body our study provides a more original way to think of the role of body parts in determining our sense of self and the symbolic meaning we attach to our body and our organs in shaping our willingness or unwillingness to donate organs to others. Finally one has to caution against the rhetoric of scarcity of organs when such rhetoric turns to scarcity and anxiety as Leslie Sharp puts it the focus and shortage of organs may neglect the role and responsibility of the transplant industry in generating its own patients a process that in turn increases the demand for organs. A promising way to do this would be to rethink the impact donation has on the selves of donors and their families and on the symbolic meaning of organ to be donated. This may pay a more promising route for public policy in this area. So thank you very much. Thank you very much. That was a terrific talk. In an area I think that we now have a lot more insight than we had at the beginning of the hour. It's great to get information about a whole different society and culture and how they look at organ donation. I guess that the first question would be do we have any indication yet on how successful a lot of the recent changes have been? So again, what we have like about 50 cases of these priority of allocation and so we know that these policy allegedly increased the number of people that assigned but unfortunately as I stated at the beginning of my lecture, these policy alternatives have yet to change the refusal rates that we have for those that sign the donor card or their families of course. So at the moment that we don't have much data on this and as I show in my research I think that the Israeli public does not support the idea of compensation. It's not connected with the policy makers initiative to try to make an incentive so if my results will... If your results are correct there won't be a significant impact. It's a very interesting kind of... Over time you'll know whether the respondents of your survey were telling the truth or not which will be interesting. Several years ago Illinois and now most of the states went through the process of a first person consent saying that the donor card that they signed is a legal document in terms of consent and that families don't have the right to overturn that. Has there been any push or a vet towards Israel? There was a bill a few years ago trying to make an opt-out system to check... This is still an opt-in but allows... It's a fully enforceable consent. So I'm not aware of such a try but even this attempt to change our legislation to make it an opt-out receive such a public... I only got down to work here but this was kind of the middle ground of a if you signed it's a legal document. Thank you Professor Sperling for your presentation. I have two questions. I was hoping you can make sense for two things that you mentioned here. One you mentioned early on that there is an increased incidence of family members who first person consent calls on people willing to donate but family members are ready to do so when it actually time to make decisions at hand. The survey that you performed here seems to be amongst people who are high school students university students and soldiers so a much younger population you said that perspective of the Israeli society at large but those are the people who might get in a car accident and then think that they want to donate but they're not the ones who are making decisions when the time has come. So how far can we take the implications of your study knowing that it's not their choice at that point. In the description of my sample the average age was 28 which is higher than soldiers or high school but it ranges. So you're correct that this sample is relatively maybe under representative in terms of the age but if you start with this education at school, in high school and you're a member of the army and you should be aware that in our system because military service is compulsory so the thinking about death and about donation is very actually something very concrete for these ages and they discuss it with their family members so it's maybe different than other cultures where there's closeness to the idea and the possibility of being endangered in a battle or in a terror attack and also I'm not saying about terror attack because it affects everyone like adult people as well so the immediacy of death in Israel if I can call it this way I think constitutes the same kind of reasoning but also tell us about the way that adult people will respond with regards to request in real time when you brought up the aspect of the compulsory military service it brings I want to get a little bit more information on what the public is a negative public reaction in terms of an opt out donor system you know in the states we kind of say the only thing that is certain is death and taxes and we don't have the compulsory medical compulsory military stuff and so the state is requiring all the young people to go into the military to protect and defend Israel wouldn't it be just another level of protection of the citizens to mandate that they donate organs so an opt out system? Yeah well that's I think a radical shift or you know because of course it's another kind of demand that you're asking people and there's a question that you know go that far to interfere within people's liberties so one can still contribute to the society by joining the army but I think to ask everyone to like to shift to an opt out would be too far in this respect I think there's also reflected in my research about the sense of the body and the closeness one feels to one's body maybe that has to be something with religion although most of the Israeli society is not religious still but the connection between religion and culture and the societal values that are shaped and constituted within the Israeli society is a very close connection it's a very tight connection so it affects also secular people in Israel I didn't quite understand what you meant by facial cells and were you talking about face transplant itself? Yeah versus face cells which would be like skin cells I'm not trying to just do that. Facial yeah so face transplant yeah we had a conference excuse me last summer in which we had several folks from Israel time who study or active in the intersection of Judaism and medicine they commented that in Israel although the nation is largely a pretty secular people that the Jewish the religious scholars have a disproportionate influence in the shaping of policies regarding medicine and you alluded to these being closely connected is that going on here as well in that the policies such as opt out would be more accepted by the general population but that the religious leaders have more influence? Yeah I think this is correct I think more generally and also to a great surprise the religious parties although they have a little share in the Israeli population they have a larger impact on biothical discourse more generally this is also reflected in reproductive ethics and other issues as well and also in this area and it starts first of all with the definition of death because Israel has a very I would well this is my criticism but again a very bizarre way of acknowledging brain death first of all the title of our legislation is Brain Respiratory Death Act which puts a lot of emphasis on the cessation of respiratory functions and requires objective testings and the specific machines and testings to be for the determination of brain death another thing that you can say that reflects the impact of religious parties is that from this new legislation which was 2008 now until this new legislation every neurologist or physician could have declared brain death you know having completed the specific testing but from 2008 onwards now only specific physicians who are trained by committee a specific committee will be allowed to determine brain death and now then you ask so who is in the committee so in the committee there are ten people three of whom are rabbis and of course this created a lot of attention I would say it elegantly in the medical profession because they say why should we be trained by rabbis how to determine death can they teach us so it took a while until they passed the law just because of that but it passed another I think example for this impact would be that our legislation the brain respiratory death act also empowers family members to dispute the determination of brain death so family members can access or can request and access the data of these testing okay and go to another physician okay that's fine but they can go to a rabbi and show him this data and allegedly the rabbi can say well I don't I'm not impressed by this data and they can come back to the hospital and say we should ask you to continue put this person on a life sustaining support um so here I mean I think New Jersey is also the same yeah so yeah but other than that so I think you can see these these points where such an influence is very very big I'm a little bit confused about the answer previously because on a previous slide you have 48.11 was the average but on a previous slide didn't you have 46 point something people who are in the age group between as I recall 16 and yeah a previous slide where you listed the people who were yeah 46.9 percent 16 to 18 so I guess I just don't quite understand how you got such a much higher median age range when you had that high a percentage of those between 16 and 18 I really appreciate your explaining the nearness to death or the awareness of risk as a maturing component of people's decisions at the time but I wonder if getting back to my earlier question about which you said Israeli law supports the family's refusal to do what the patient has asked does that carry over to what we call in this country advanced directives in general that the family is always able to override what the patient stipulates in terms of advanced directives so no it doesn't go that far it's only when the patient is dead and Israel has a recent law on end of life issues that validated the effect of advanced directives but there you have full validation by the authority of the person who initiated who completed this advanced directive so yeah so in the United States if you donate a kidney you're then no longer eligible to enroll in the army you can actually donate a kidney while you're in the army but if you've already donated they're not going to take you with mandatory service I wonder if there's any consideration that people have to donate after mandatory service or it's not an issue in Israel no it's not an issue and I would doubt that we have such a similar rule saying that if you donated you're not allowed to even if you wanted to no it's not no but they go to the army in the age of 18 but they're eligible but they can donate while in the army yeah go ahead I was struck by the centrality that you attribute to the concept of sense of self and I wondered if you could say a little bit more about how that is being used okay so it hasn't been used as a find yet because these are new findings and as you see it's a quantitative research so I think it should be followed up by a qualitative research to explore more maybe with focus groups on the meaning of the sense of self and the attachment that one places on the body and their role in the shape of the way they see themselves so these are the findings I'm going to have so far we've heard a lot about the buying and selling of organs in Israel did the law in 2008 result in a decrease in that practice? one of the good things that it did was to better enforce the commerce that was done outside Israel, not inside Israel inside Israel we don't have evidence for that I don't know I've just heard a story about something going on in Cleveland Medical Center but I don't know at least with regard to the Israeli so what the law did was prohibited the reimbursement of transplant surgeries that were done outside Israel unless you prove that there's no commerce first of all it has to be like in a respectful medical institution and they're reviewing lots of documents and this wasn't before so yeah and another thing that the law did was to create these criminal offenses with regards to trade in humans for organ sale and even an offense to buy or sell an organ although they cannot be prosecuted as opposed to Singapore for example where they can prosecute the seller of an organ as well very interesting it's getting to one o'clock so thank you very much thank you