The use of financial incentives for donors is among the methods that have been recently debated in an effort to improve organ supply for kidney transplantation [1]. The Transplantation Society guidelines for the donation of kidneys by LUDs forbid payment to the donor by the recipient, the recipient's relatives, or any supporting organization [2].

The main arguments against donor financial compensation are that 1) it is morally reprehensible and would damage the public's will to act altruistically; 2) it would lead to preferential distribution of organs to the wealthy and might lead to coercion and exploitation; 3) it might stimulate organ donation from persons who are not medically suitable; 4) it might lead to a decreased effort to achieve more suitable donor-recipient matches; and 5) it could impair the development of cadaveric organ transplantation programs.

In our study, we found that LUDs may be indicated for recipients for whom neither a living, related nor a cadaveric donor is available. However, before we resort to financial incentives for the donor, more urgent alternatives exist to increase the supply of organs. Many more organ donors are available worldwide than are being accessed through existing organ procurement efforts. In the United States, the number of available donors could be increased by 80% [3]. In developing countries, organ procurement could be better organized. In Brazil, lack of motivation and of efficiency of medical teams attending potential donors rather than lack of suitable organs seems to be the problem [4]. Recent organ procurement efforts in Sao Paulo have significantly increased cadaveric organ transplantation activity. Currently, more than 80% of the approximately 120 kidney transplants done each year at Escola Paulista de Medicina are with cadaveric donors.

A major concern about the practice in India relates to donor selection. All donors were from the lower stratum of society and in great financial need. Their follow-up has been poor. In addition, the practice of transplantation of kidneys from LUDs may have impaired the development of living, related and cadaveric transplant programs in India.

If transplant physicians in India or elsewhere believe that paid donation is the only way to keep their patients alive, and they have community support, who are we to condemn them? The ethics of treating end-stage renal disease in Western culture may not apply in India [5]. In our opinion, however, the benefits from direct payment for organs from LUDs in our country do not outweigh the ethical arguments against its practice.