Recent arrests in Lahore of people involved in illegal kidney transplants have brought this issue back into the limelight, sort of. Over the last couple of years, new laws about transplantation have undoubtedly decreased the number of ‘unrelated donor’ transplants but the practice continues and if not checked will slowly increase in frequency. As such the fact that the Punjab police is pursuing this matter aggressively is a welcome piece of news. For those who might not be aware, the most important part of the new laws concerning transplants is that people not closely related to the recipient of the organ are not allowed to donate the organs. The major target of these laws is the kidneys that are sold for transplantation. The unfortunate fact is that the need for kidneys far exceeds the number that are available for transplantation and therefore many patients that desperately need them are condemned to a life of severe disability and suffering. The only way to ameliorate this situation is to increase the pool of available donors. The best way to enlarge the pool of potential donors is to include ‘recently deceased’ people as possible sources of organs for transplantation. In most countries such organs are the commonest available for transplantation and even though the law permits them in Pakistan, such donations are virtually unheard of. Recently deceased donors are divisible into two categories. Those who have actually died and those who are brain dead but have a functioning heart that is keeping the organs alive. The first group is obviously the larger pool of donors. Before such donations, even though legal, become a reality, three major changes will have to take place. First, a major public awareness campaign that makes such donations acceptable to most people. Second, the training and education of the ‘first responders’ (rescue squads and ambulance crews) that provide initial care to accident victims and patients with life-threatening conditions so that they can identify potential donors and transport them to appropriate facilities. Third, and probably the most important, is the availability of medical facilities where physicians and other medical staff can prepare these patients and their families for subsequent donation of different organs once death becomes imminent. Brain dead donors constitute a special category among ‘recently deceased’ patients since they can also provide the heart for subsequent transplantation. However, the care of brain dead donors with a beating heart requires special expertise to keep their bodies in good enough condition to enable subsequent donation of organs. But all this can only happen once the general public is willing to accept that after their loved ones are gone, donation of their organs to needy people would be a superlative act of kindness. Unfortunately, altruism is rarely enough impetus, at least in our present environment. Therefore, some extraordinary efforts might be needed to create public awareness and acceptability of donation of organs from recently deceased relatives. One suggestion worth considering is monetary awards for organ donation. For instance, if it is publicised that any recently deceased person’s family will receive a generous amount of money for every organ donated, that could be a great incentive. Some might call this idea crass and inhumane. But then what is life insurance after all? You pay us and when you die we will pay your family. Of course the source of this financial payment has to be from public funds or from donations but not directly by the possible recipient of a donated organ. Surely a mechanism can be developed to provide such funds without involving any future recipient directly. Is there going to be some room for chicanery, indeed yes, but proper oversight by an independent board of transplantation can keep this at a minimum. And now to where we started from, the question of unrelated living donations. It is a simple fact that when healthy adults donate a kidney under proper medical supervision, they can go on to live a healthy and normal life. That institutions like the Sindh Institute of Urology and Transplantation (SIUT) perform hundreds of successful kidney transplants every year from related healthy donors confirms this fact. Another fact to be considered is that even if transplants from recently deceased people become common, there will still be patients who have to wait for appropriate donors and many will die while waiting. Therefore, as long as there exists the need and there are people willing to pay to fulfil that need the illegal sale of kidneys is likely to continue in some form or the other. The question then is, should unrelated donors be allowed to donate kidneys for money? This is not only a medico-legal question but also involves moral attitudes. So far in transplant circles, such an exchange has been thoroughly proscribed but even in the US there are some experts advocating that some such exchange of organs for money should be permitted. Modern techniques for harvesting kidneys by expert surgeons using small incisions (laparoscopic methods) can tremendously decrease the morbidity of the harvesting procedure and return the donors to normal activities much sooner. My suggestion then is that payment for kidneys should be allowed under very strict guidelines. Prospective ‘volunteer’ donors should be enlisted in a national registry, they should receive appropriate medical screening and if needed treatment for any minor medical problems. The donors should be matched to anonymous recipients on another nation registry. Before the donors undergo the harvesting of organs they should receive a generous initial payment equivalent perhaps to the price of a new Toyota Corolla. After the transplant is done, the donors should receive a monthly stipend of minimum wage plus 50 percent medical care and follow up for the rest of their lives. More importantly, if the organs from the young people dying needlessly from accidents and random violence are donated to needy patients then we can at least say to the relatives that their loved ones did not die in vain. The writer has practised and taught medicine in the US. He can be reached at smhmbbs70@yahoo.com