JERUSALEM — In the Book of Genesis, it is written that when the great flood submerged the land it extinguished “all in whose nostrils was the breath of life.” Across nearly 2,000 years of Talmudic debate, Jewish scholars have returned to that verse in holding that life ends at the moment when breathing stops. One 19th-century code instructed that if a person appeared lifeless, a light feather was to be placed before his nose: “If it does not flutter,” the text advised, “he is certainly dead.”
The sages could not have anticipated that their writings would provide the underpinnings for cultural resistance to organ donation from the deceased in 21st-century Israel. But their definition of mortality, which can conflict with modern acceptance of brain death, is cited among several reasons Israel has among the lowest rates of deceased organ donation of any developed country.
The resulting five-year waits for a kidney from a cadaver help explain why this tiny nation has played an outsize role in the global organ trade, experts say.
Since 2000, one trafficking prosecution after the next has implicated Israelis in some way. Although recent legal changes have made it less enticing for Israelis to seek transplants overseas, they have contributed to longer wait lists at home. That has kept organ brokers in business.
“The continued driving force is the lack of deceased donation in Israel and the concept that every rich person worldwide would rather put a stranger at risk than a relative,” said Dr. Jeremy R. Chapman, an Australian nephrologist and past president of the Transplantation Society.
Despite its advanced medical infrastructure, Israel trails comparable countries in most measures of organ donation. In 2012, it had 7.4 deceased donors per million population, ranking it in the bottom third of countries surveyed by the Council of Europe. The rate was 18.5 in Britain, 25.8 in the United States and 35.1 in Spain.
About 15 percent of Israeli adults are registered as donors, according to the Health Ministry’s National Transplant Center, compared with nearly half in the United States.
“If someone is planning on going through a transplant, waiting to get a kidney in the country, there is a greater chance that the Messiah will come,” said Amos Canaf, founder of an Israeli advocacy group for renal patients.
Opposition to organ donation from the deceased runs contrary to both government policy and pronouncements of the chief rabbinate. But it has been embraced by a core of ultra-Orthodox rabbis with trickle-down influence.
Although many Israelis are secular, even nonreligious Jews grasp for the faith’s instructions at the end of life. “At times of death and mourning, a person remembers his roots,” said Rabbi Shlomo Amar, a former Sephardic chief rabbi who accepts the brain death definition.
The collision of ancient theology and modern bioethics reached its apotheosis with the high-profile case of Avi Cohen, an Israeli soccer legend who was declared brain dead after a motorcycle accident in 2010. Informed that Mr. Cohen, 54, was a registered donor, his family initially granted permission to recover his organs. As a matter of practice, hospitals in Israel will not proceed without a family’s consent.
But with his breathing maintained by a ventilator, Mr. Cohen appeared lifelike. His devastated wife and children could not drown out the voices of visitors to his bedside who cautioned he might still revive.
“We wanted to believe in anything,” recalled Dorit Cohen, Mr. Cohen’s widow. “To take the last step and end his life is something I could not do.”
Today, Ms. Cohen regrets her reversal. “Avi would do anything to help people,” she said. “I’m sure he would not have agreed with my decision.”
Among the religious obstacles to donation is a belief by some traditional Jews in physical resurrection, and a conviction that the body should not be desecrated before burial. Physicians and ethicists also remark on a cultural resistance to asking relatives to donate. For years, state policy essentially supported transplant tourism by allowing insurers to reimburse patients who went overseas.
“The general mentality of the public, and of many rabbis, is that they don’t see why people should risk their lives if there is somebody in Ecuador willing to sell them a kidney,” said Dr. Yechiel Michael Barilan, an Israeli physician whose book, “Jewish Bioethics,” was published this year. “There is no sensibility about the social dynamics of exploitation.”
While Jewish law commands that almost anything can be done to save a life, it holds that one life is not to be sacrificed to save another. Because the risk of death from kidney retrieval surgery is low, organ donation by the living is encouraged. But some Jews consider it murder to retrieve organs before the heart and lungs stop functioning.
Rabbi Yeshayahu Heber, who received a kidney from a friend seven years ago, became so convinced of the blessedness of altruistic living donation that he started an organization to encourage it among observant Jews. His group arranged 60 living-donor transplants last year. And yet, Rabbi Heber said he accepted the teachings of revered rabbis that it is against Jewish law to recover organs from the brain dead.
The concept of brain death, defined as the irreversible cessation of brain function, started gaining worldwide acceptance in the late 1960s. It is considered the optimal circumstance for deceased donation because the patient’s organs continue to be oxygenated through mechanical ventilation, maintaining their viability.
In 1986, Israel’s chief rabbinate — two Orthodox rabbis elected by peers — endorsed it as a criterion for determining death. But fearful that doctors would rush brain death determinations in order to retrieve organs, they insisted that brain death panels include a rabbinical representative.
Resentful of the intrusion, the medical establishment refused. That prompted some rabbis to continue to discourage donation and to avoid taking public stands against organ trafficking.
“As a matter of public policy, we really didn’t hear any voices,” said Rabbi Avraham Steinberg, a neurologist and leading medical ethicist.
In 2006, responding to reports that Israelis were buying kidneys in places like China and the Philippines, the Health Ministry prohibited insurers from paying for illicit overseas transplants. In 2008, the Israeli Parliament passed legislation that criminalized organ brokering and established panels to scrutinize whether donors are being compensated. It also provided for government payments for a donor’s medical care and related monetary losses.
And in a unique move, the law authorized the Health Ministry to give preferential status on transplant wait lists to registered donors and those who have consented to a relative’s donation.
“It is deviating from pure altruism to reciprocal altruism,” said Dr. Jacob Lavee, a heart transplant surgeon who helped shape the law.
A second law established protocol for determining brain death and gave rabbis seats on a committee that monitors doctors who make those decisions.
The signs of improvement include a record 261 kidney transplants last year, driven by a significant increase in living donor transplants. There has been a corresponding drop in the number of patients who are known to have gone abroad, to 43 in 2013 from a peak of 155 in 2006. Donor registrations have increased by two-thirds.
But other results have disappointed. The kidney transplant wait list of about 750 people is 40 percent longer than when the laws passed. And the rate at which families refuse to donate a relative’s organs — about 50 percent — is virtually unchanged. The refusals meant 260 lost donation opportunities over the last four years.
Some Israelis favor the more radical solution of legalizing compensation for donors. Government regulation could reduce the risk of exploitation, they say, by controlling pricing and ensuring quality care.
“I don’t really see the strong argument for letting someone die when you have the option of saving someone’s life,” Rabbi Steinberg said.
Although opposed by global health organizations, legalizing commercial donation is not the fringe position it once was. In July, the American Society of Transplantation and the American Society of Transplant Surgeons called for pilot projects to test incentives for donation, potentially including cash payments. Such changes would require amending a 30-year-old federal law.
Dr. Daniel R. Salomon, past president of the American Society of Transplantation, said it was no longer enough to rely on altruism. “We have been passive over the last several years during a time at which it’s clear that our waiting list is continuing to go up much faster than we can get organs,” he said.
Researchers in the United States and Canada have estimated that payments of $15,000 for a kidney could produce a meaningful increase in available organs.
Dr. Sally L. Satel of the American Enterprise Institute, a proponent of compensating donors, said she thought the price might need to be $50,000. “The lower you go, you get closer to exploitation,” said Dr. Satel, a psychiatrist who received a kidney from a friend in 2006.
Others favor experimenting with alternative compensation, including long-term health coverage, tax credits and tuition vouchers.
Those who support compensation argue that there may be no other way to destroy the black market. They also question whether buying a kidney is different than paying for gestational surrogacy or for eggs, sperm and plasma.
Opponents fear commercialization would undercut altruistic organ donation. And transplantation experts like Dr. Luc Noël of the World Health Organization, insist it will reinforce class divisions.
“If you have a line of naked individuals,” Dr. Noël said, “devoid of external signs of societal position, and you can recognize the rich from the poor simply by counting their kidneys, is that the kind of world you want to live in?”