Ethics in organ donation: contrasts in two cultures.

1. For cadaveric organs in the West, there are many avenues that should be pursued in order to increase the supply. Most of the measures under "giving" in Table 2 are ethical, though we do not accept the implication that those who enroll, in advance, as future organ donors should thereby obtain priority for their own possible future transplant organ needs. 2. "Legislated taking" could be ethically justified if shown to be acceptable to most persons in a society or culture, with provision for opting out for those with minority opinions and beliefs. Such evidence should be sought, and acted upon if found to be present. It certainly warrants a strong public education thrust. 3. Possibilities should be explored for nonmonetary rewarding of families of the decreased, in ways that would not foreclose on families giving authorization for purely altruistic reasons. Direct money payments, "buying," will never outweigh the ethical arguments against the practice, in our opinion. There are other societal avenues by which to pursue the perfectly acceptable goals of indirect altruism. 4. For kidney donations from unrelated living donors in India, a case is made for considering rewarded gifting as being ethically acceptable if it is defined in the way that it is carefully defined for this article, provided it meets the criteria for indirect altruism of a panel of social peers, and also is linked to measures of mandated philanthropy (decided also by a panel of social peers), for the reasons given. This is a balance of societal burden (in allowing rewarded gifting) by the ensured benefit to the seller (to prevent his victimization) plus a required benefit to society by seller's philanthropy. The setting of these balances should be decided by a panel of social peers. Such acceptance would not necessarily pass muster for other cultures than the one for which it is designed. 5. All forms of commerce, included that described in the preceding paragraph, become ethically unacceptable if the regulations governing them cannot realistically be enforced. This is a crucial point, a requirement for ethical cogency.