Who Decides? Priorities in Kidney Donation

Living kidney donation exists at the intersection of medicine, ethics, and Halacha. In Israel, as in many nations, a system has evolved with the dual purpose of saving lives while maintaining fairness, safety, and authentic free choice. Within this structure, an important question frequently arises: should donors be permitted to know the recipient’s identity or to influence the selection of the recipient?

In clinical practice, living kidney donation typically follows one of two primary pathways. The first is a directed donation, in which the donor provides a kidney to a specific recipient – such as a family member, friend, or acquaintance – and both parties are usually acquainted before the donation. The second pathway involves altruistic, or non-directed, donation to an anonymous recipient. In these cases, the standard protocol is to maintain anonymity between the donor and recipient to minimize potential emotional pressures, obligations, or other external influences.

However, there is no rule requiring absolute anonymity. The identities of the donor and recipient are not typically disclosed to each other before the transplant; such disclosure requires careful consideration and formal approval. After the procedure, contact between the donor and recipient may be allowed, provided it is with mutual consent and with proper authorization. Additionally, in Israel, altruistic donors may specify general preferences regarding the type of recipient, provided these preferences do not involve discrimination and adhere to established guidelines.

In a non-directed donation, recipient selection is primarily determined by medical criteria: blood type compatibility, crossmatching, and evaluation of the likelihood of transplant success and the anticipated medical benefit. In essence, the allocation is guided by medical considerations intended to optimize outcomes and save lives, rather than by the donor’s preference for a particular recipient.

By contrast, in a directed donation, the optimal matching is not a consideration. In such cases, the only factors examined are the medical need for a transplant, compatibility, and the prospects for success.

This distinction raises a significant halachic question: If an individual intends to donate a kidney to a relative or friend, is he permitted to do so without restriction? Alternatively, should precedence be given to an unknown patient with a more immediate, life-threatening need, rather than to a relative or friend whose condition may not be as urgent?

In Hilchos Tzedaka, clearly established hierarchies of precedence exist. As elucidated by haGaon Rav Asher Weiss shlit”a, four categories of priority are recognized: first, the objective of the Tzedaka (for instance, life-saving interventions as compared to Torah study or general support for those in need); second, the nature of the necessity, such as food or clothing; third, the manner in which the charity is dispensed, as outlined in Shulchan Aruch, Y.D. 249, which enumerates eight progressively meritorious levels of giving; and finally, the hierarchy most pertinent to this discussion—the order of priority concerning the recipients themselves.

The Shulchan Aruch (Y.D. 251) rules:

One who supports his adult sons and daughters, though no longer legally obligated to provide for them, to educate his sons in Torah and guide his daughters in the correct path – or one who gives gifts to his father when he is in need – this is considered Tzedaka. Moreover, these individuals take precedence over others. Even if the recipient is not his child or father but another relative, that relative takes priority over others. A paternal brother precedes a maternal brother. The poor of one’s household come before the poor of one’s city, and the poor of one’s city before those of another city.

The Rema adds:

One’s own livelihood takes precedence over all others. A person is not required to give Tzedaka until he has secured his own sustenance. Thereafter, his father and mother, if they are poor, take precedence – even before his children. His children follow, then his siblings, then other relatives. Relatives precede neighbors; neighbors precede residents of one’s city; and residents of one’s city precede those of another city. The same order applies to redeeming captives.

This priority is not confined to Hilchos Tzedaka. Across multiple domains, Halacha consistently maintains a favorable stance on granting precedence to family members.

For example, the Gemara states (Yevamos 62b-63a):

One who loves his neighbors, draws his relatives close, marries his sister’s daughter, and lends money to a poor person in his time of distress: regarding him, the Pasuk states: ‘Then you shall call, and Hashem answer; you shall cry, and He will say: Here I am’” (Yeshaya 58:9).

The Pasuk quoted by the Gemara concludes a passage that begins: “Is it not to share your bread with the hungry, to bring the poor into your home; when you see the naked, to clothe him – and not to hide yourself from your own flesh?” The Gemara explains that the phrase “and not to hide yourself from your own flesh” includes the obligation to draw one’s relatives close, even to the extent of preferring marriage to a niece over marrying a woman with whom one has no familial bond.

“Drawing one’s relatives close” means giving them preference over others. As the Rambam explains in Moreh Nevuchim (3:42):

Our Sages greatly praised the quality of drawing one’s relatives near, and of marrying one’s sister’s daughter. The Torah informs us that this carries great weight: a person should show special regard for his relatives and draw close all who share kinship with him. Even if a relative has wronged him or acted unjustly toward him – even if that relative is in the most degraded state – he cannot withhold regard from his kin.

As we have seen, in Hilchos Tzedaka, this is indeed the basic rule: one’s relatives take precedence over others.

The rationale for this hierarchy is clear and grounded in fundamental human tendencies: individuals prioritize their own well-being, that of their families, and of those closest to them. As such, if one does not attend to their own relatives’ needs, it is unlikely others will show the same level of care. This principle underlies the established order of precedence.

Does this priority apply to medical care?

The Ya’avetz examines this issue comprehensively in his Sefer, Migdal Oz (Even Bochan, from section 89 onward). In his analysis of priorities in life-saving situations, he rules that such priorities are influenced by familial proximity in accordance with the hierarchy of inheritance. For example, saving a son is given precedence over saving a brother.

… whoever is closer takes precedence. When the two are otherwise equal (meaning that if one of them is one’s teacher or holds another form of precedence, that factor may override family priority). Everything follows the same pattern as in Hilchos Tzedaka and redeeming captives.

Put simply, Halacha recognizes the concept that relatives take priority over others, even in medical care. However, it should be emphasized that the various hierarchies in the laws of saving lives are rarely applicable in practice for several reasons. Foremost is the obligation to save whoever is in the most urgent danger, and whoever is most likely to benefit from treatment. For this reason, life-saving decisions are generally made without regard to other considerations. When multiple lives are at stake, urgency and medical prognosis almost always determine the outcome.

Our situation may differ from other scenarios of life-saving interventions. In typical cases, there is an explicit obligation to assist others and a prohibition against remaining passive in the face of another’s peril (Vayikra 19:16^[1]). Priority should be accorded to individuals facing greater immediate danger. Regarding kidney donation, however, many Poskim maintain that there is no absolute requirement to donate an organ; rather, it constitutes an exceptional act of piety and generosity, an individual offering a part of their own body to preserve another’s life. While such donors fulfil the Mitzva of saving life in an exemplary manner, it is not considered compulsory. Consequently, there does not appear to be a strict mandate to donate specifically to the person with the most urgent need.

Another important factor is that, in practice, organ transplants are typically performed using public medical resources. The Chacham Tzvi (Shu”t 70) notably maintains that the principle of giving precedence to relatives in matters of Tzedaka pertains only when an individual is distributing personal funds and must determine whom to assist. Conversely, when acting as the administrator of a public charitable fund, it is inappropriate to show preferential treatment toward one’s relatives. In such cases, only the broader halachic principles of priority should be observed – for instance, giving precedence to a Torah scholar over an unlearned individual, along with similar considerations.

The same principle applies to a physician employed in the public healthcare system. As a salaried professional utilizing publicly funded facilities and equipment, which, for these purposes, may be regarded as communal resources, there is no justification for preferential treatment toward relatives. These assets are neither his personal property nor provided through his own means or discretionary time. Since the public collectively owns them, it is inappropriate for a physician to advance his family members at others’ expense.

This distinction is particularly relevant in situations where a physician, by virtue of his connections, can secure faster treatment for a relative (e.g., an earlier surgery date, expedited access to a specialist, or priority over others waiting in line). Similarly, a medical consultant with professional ties might be able to advance appointments for testing or evaluation. If two people approach him for assistance, he would have no right to promote his relative over the other simply because of family ties. Since this does not involve his own assets or private Tzedaka, but the allocation of public resources, he must follow the established Halachic criteria of priority. Only if the two candidates are equal in those respects may he choose to assist his relative first.

However, our situation may differ. Although the transplant uses public medical resources, the donor still has the right to refuse donation unless he can direct his kidney to a relative. If this is his stipulation, there appears to be no reason to object to using public resources for this purpose. Ultimately, the transplant remains a crucial, life-saving procedure, even if another recipient might have been preferred from a strictly medical standpoint.

In Sefer Nes l’Hisnoses (67), Rabbi Yitzchak Zilberstein addresses the issue of prioritization in life-saving scenarios. He examines the situation in which an individual witnesses two people drowning in a river, with one person located nearer than the other. Citing the opinions of the Poskim, he explains that priority should be given to the mitzvah that presents itself first, adhering to the principle of Ein Ma’avirin Al haMitzvos. Consequently, the rescuer is obligated to assist the closer individual before attending to the second.

He adds:

I heard from my father-in-law, R’ Elyashiv, that if the one farther from him is his son, he may save him first. Just as the rescuer’s own life takes precedence over that of another, so does his son’s life take precedence, for “Bra Kara d’Avuha.” Similarly, regarding the return of lost property: if one encounters his fellow’s lost item, and from a distance sees the lost item of his son who is dependent on him, he may pass over the first and attend to his son’s, for it is considered like his own. We also learn in Sefer Ahavas Chesed (Dinei Halva’ah, 6:11) that if someone knows a relative will soon need to borrow money, they may choose not to lend to an unrelated poor person, since the duty of kindness is stronger toward relatives. This principle also appears to extend to rescue situations; relatives are prioritized.

This is a notable position, asserting that an individual may consistently prioritize his son above others. Similarly, it appears permissible to give precedence to family members and friends, even when a stranger may have a more urgent need for the donation based on objective medical criteria. The underlying rationale remains consistent with what was previously explained.

[1] “Lo Sa’amod Al Dam Rei’acha”